Riel, Piet L. C. M. van

Objectives The impact of body mass index (BMI) on cardiovascular risk in rheumatoid arthritis (RA) is unclear. RA characteristics may influence the association between BMI and risk. Disease activity, which predicts cardiovascular risk, is associated with obesity only among anticitrullinated antibody (ACPA)-positive patients. Biologics alter body composition and mitigate cardiovascular risk in RA. We explored the association of BMI with cardiovascular risk and whether this varied across ACPA status and biologic use. Methods We evaluated 3982 patients from an international observational cohort. Outcomes included (a) first major adverse cardiovascular event (MACE) encompassing myocardial infarction, stroke or cardiovascular death; and (b) all events comprising MACE, angina, revascularisation, transient ischaemic attack, peripheral arterial disease and heart failure. Multivariable Cox models stratified by centre risk evaluated the impact of BMI, ACPA, biologics and their two- and three-way interactions on outcomes. Results We recorded 192 MACE and 319 total events. No main effects of BMI, ACPA or biologics were observed. A three-way interaction between them on MACE (p-interaction<0.001) and all events (p-interaction=0.028) was noted. Among ACPA negative patients, BMI was inversely associated with MACE (HR 0.38 (95% CI 0.25 to 0.57)) and all events (HR 0.67 (0.49 to 0.92)) in biologic users but not non-users (p-for-interaction <0.001 and 0.012). Among ACPA-positive patients, BMI was associated with MACE (HR 1.04 [1.01–1.07]) and all events (HR 1.03 (1.00 to 1.06)) independently of biologic use. Conclusions BMI is inversely associated with cardiovascular risk only among ACPA-negative biologic users. In contrast, BMI is associated with cardiovascular risk in ACPA-positive patients independently of biologic use.

Aim The objective was to examine the prevalence of atherosclerotic cardiovascular disease (ASCVD) and its risk factors among patients with RA with diabetes mellitus (RA-DM) and patients with RA without diabetes mellitus (RAwoDM), and to evaluate lipid and blood pressure (BP) goal attainment in RA-DM and RAwoDM in primary and secondary prevention. Methods The cohort was derived from the Survey of Cardiovascular Disease Risk Factors in Patients with Rheumatoid Arthritis from 53 centres/19 countries/3 continents during 2014–2019. We evaluated the prevalence of cardiovascular disease (CVD) among RA-DM and RAwoDM. The study population was divided into those with and without ASCVD, and within these groups we compared risk factors and CVD preventive treatment between RA-DM and RAwoDM. Results The study population comprised of 10 543 patients with RA, of whom 1381 (13%) had DM. ASCVD was present in 26.7% in RA-DM compared with 11.6% RAwoDM (p<0.001). The proportion of patients with a diagnosis of hypertension, hyperlipidaemia and use of lipid-lowering or antihypertensive agents was higher among RA-DM than RAwoDM (p<0.001 for all). The majority of patients with ASCVD did not reach the lipid goal of low-density lipoprotein cholesterol <1.8 mmol/L. The lipid goal attainment was statistically and clinically significantly higher in RA-DM compared with RAwoDM both for patients with and without ASCVD. The systolic BP target of <140 mm Hg was reached by the majority of patients, and there were no statistically nor clinically significant differences in attainment of BP targets between RA-DM and RAwoDM. Conclusion CVD preventive medication use and prevalence of ASCVD were higher in RA-DM than in RAwoDM, and lipid goals were also more frequently obtained in RA-DM. Lessons may be learnt from CVD prevention programmes in DM to clinically benefit patients with RA .

Abstract Aims To assess differences in estimated cardiovascular disease (CVD) risk among rheumatoid arthritis (RA) patients from different world regions and to evaluate the management and goal attainment of lipids and blood pressure (BP). Methods and results The survey of CVD risk factors in patients with RA was conducted in 14 503 patients from 19 countries during 2014–19. The treatment goal for BP was &lt;140/90 mmHg. CVD risk prediction and lipid goals were according to the 2016 European guidelines. Overall, 21% had a very high estimated risk of CVD, ranging from 5% in Mexico, 15% in Asia, 19% in Northern Europe, to 31% in Central and Eastern Europe and 30% in North America. Of the 52% with indication for lipid-lowering treatment (LLT), 44% were using LLT. The lipid goal attainment was 45% and 18% in the high and very high risk groups, respectively. Use of statins in monotherapy was 24%, while 1% used statins in combination with other LLT. Sixty-two per cent had hypertension and approximately half of these patients were at BP goal. The majority of the patients used antihypertensive treatment in monotherapy (24%), while 10% and 5% as a two- or three-drug combination. Conclusion We revealed considerable geographical differences in estimated CVD risk and preventive treatment. Low goal attainment for LLT was observed, and only half the patients obtained BP goal. Despite a high focus on the increased CVD risk in RA patients over the last decade, there is still substantial potential for improvement in CVD preventive measures.

Abstract Background/Introduction The realisation that subjects with rheumatoid arthritis (RA) are at increased risk of cardiovascular disease (CVD) has led to a growing interest in risk factor control in such people, but whether this has influenced the management of dyslipidaemia and hypertension (HT) is uncertain. Purpose To describe differences in lipid and blood pressure (BP) levels among patients with RA from five world regions. Furthermore, to evaluate attainment of guideline recommended targets for lipid lowering and antihypertensive treatment. Methods The SUrvey of CVD Risk Factors in patients with RA (SURF-RA) was conducted at 53 centres in 19 countries from 2014 to 2019. Data including demographics, RA disease characteristics, CVD comorbidity, risk factors and use of preventive treatment was collected. HT was defined as self-reported HT, and/or measured BP &gt;140/90 mmHg, and/or use of anti HT medication (a-HT). The treatment goal of a-HT was BP &lt;140/90 mmHg. The 10-year risk of a fatal CVD event was calculated by the European CVD risk calculator, the Systematic COronary Risk Evaluation (SCORE), and was thereafter multiplied with 1.5 as recommended by the European League Against Rheumatism. Patients were classified in a high or very high CVD risk group according to the 2012 European Society of Cardiology guidelines, with low density lipoprotein cholesterol (LDL-c) goal at &lt;2.6 and &lt;1.8 mmol/L, respectively. Results In total, 14503 RA patients were included. The mean age was 59.8±13.6 years, most of whom (74%) were female. Nearly 2/3 of the patients were hypertensive. Use of a-HT in the total population differed substantially between the cohorts with limited use in West Europe and Latin America (17.4% and 24.8%), in contrast to North America and East Europe (46.8% and 57.0%). On average, half of those with HT were at the recommended BP goal. The lowest BP goal attainment was seen in Asia, West and East Europe (40.8–43.1%), and the highest in North America (63.5%). Overall 51.5% had an indication for lipid lowering therapy (LLT), and of these only 43.5% were taking LLT. Only 34.0% of patients with an indication for LLT were at recommended LDL-c goals. The proportion of RA patients on target for LDL-c varied greatly between regions, from 23.1% in East Europe to 51.0% in North America. The LDL-c goal attainment was higher in RA patients at high risk (45.1%) compared to those at very high risk of CVD (18.0%). Conclusion(s) This large international survey on RA patients revealed considerable geographical differences in CVD preventive treatment. Only one half of subjects were at blood pressure goals, and achievement of lipid goals was even poorer at one third of those eligible for treatment, which is lower than what is reported for subjects with coronary heart disease. We conclude that there is a substantial need for improvement in CVD preventive measures in RA patients. Funding Acknowledgement Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Unrestricted research collaboration with Lilly

Abstract Background The cardiovascular disease (CVD) risk in patients with rheumatoid arthritis (RA) is comparable to that of patients with diabetes mellitus (DM). Although several studies have indicated high prevalence's of DM in RA patients, little is known about how this affects their CVD risk. Objectives To examine indications for, and use of antihypertensive treatment (a-HT) and lipid-lowering therapy (LLT) in RA patients with DM (RA-DM) and RA patients without DM (RAwoDM). Further, to compare the prevalence of various types of CVD across RA-DM and RAwoDM. Methods The cohort was derived from the SUrvey of cardiovascular disease Risk Factor in patients with Rheumatoid Arthritis (SURF-RA), which was performed in 53 centres/17 countries in 5 world regions (West and East Europe; North and Latin America; and Asia) from 2014 - 2019. Indication for a-HT was defined as: 1) systolic/diastolic blood pressure (BP) ≥140/90 mm Hg, 2) self-reported hypertension, and/or 3) current use of a-HT. Indication for LLT was defined according to ESC guidelines. CVD risk estimates (by SCORE) were multiplied by 1.5 according to EULAR recommendations. Target treatment targets for BP and lipids were defined according to ESC guidelines applicable at the time data were recorded. Results Presence of comorbid DM was available in 10 602 (73.1%) of the 14 503 RA patients included in SURF-RA, of whom 75 and 1262 patients reported DM type 1 and type 2, respectively (total 1337 patients, 12.6%). Although less often current smokers, RA-DM patients were more often previous smokers, male sex and had higher body mass index compared to RAwoDM (p&lt;0.0001 for all). a-HT (84.7% vs 62.3%) and LLT (100% vs 47.2%) were more frequently indicated in RA-DM than in RAwoDM patients (p&lt;0.0001 for both). RA-DM were more likely than RAwoDM to receive a-HT on indication (60.4% vs 57.6%, p&lt;0.0001), while the difference in LLT use on indication was not significantly different (45.7% vs 42.5%, p=0.06). Moreover, RA-DM compared to RAwoDM patients had more often reached treatment goals when on a-HT (60.7% vs 54.1%, p&lt;0.0001) and LLT (62.8% vs 48.9%, p&lt;0.0001). Finally, the risk of all recorded established CVD (coronary heart disease, stroke, peripheral artery disease and atrial fibrillation) was increased by a factor of 2 to 3 in RA-DM compared to RAwoDM (Figure). Conclusion The effect of RA and comorbid DM on CVD risk appears to be additive. While CVD preventive medications are more often indicated in RA-DM than in RAwoDM patients, they are also more likely to receive such therapy and to reach CVD preventive treatment goals. The latter finding may be due to more developed CVD preventive care in DM compared to RA patients. Improved CVD preventive systems for patients with RA are warranted. CVD in RA patients with and without DM Funding Acknowledgement Type of funding source: Other. Main funding source(s): Lilly

Abstract Background Patients with rheumatoid arthritis (RA) are at high risk for cardiovascular disease (CVD). Purpose The aim of this survey was to evaluate updated information on CVD risk factors, comorbidities, RA disease characteristics, RA and CVD preventive medication in patient with RA. Methods The audit is termed SUrvey of cardiovascular disease Risk Factors in patients with Rheumatoid Arthritis (SURF-RA) and was performed in 53 centres/19 countries/5 world regions in 2014–2019. SURF-RA have been performed in patients with coronary heart disease, in primary care, and now in patients with stroke, SLE and antiphophlipid syndrome. The survey was approved by the Data Protection Officer (2017/7243) and a GDPR evaluation has been performed (10/10–2018). Results Among 14 503 patients with RA in West (n=8 493) and East (n=923) Europe, Latin (n=407) and North (n=4 030) America and Asia (n=650) the mean (SD) age was 59.9 (13.6) years, and 2/3 or more were female (table). RA disease duration was comparable across the world regions, ranging from 9.9 to 12.6 years. The prevalence of atherosclerotic CVD (ASCVD) was lowest in Latin America (2.5%) and highest in East Europe (21.4%), and this pattern was similar regarding familial premature CVD. The mean prevalence (% of each entity) of blood pressure above 140/90 mmHg was 5.3%, of low density lipoprotein cholesterol &gt;2.5 mmol/L: 63.3%. Overall, 29% used antihypertensive medication, lowest in West Europe (17.4%) and highest in East Europe (57.0%), and 26.4% used lipid lowering agent(s), lowest in Asia (7.2%) and highest in North America (31.1%). Body mass index &gt;30 kg/m2 was present in 26.6%, with the smallest waist circumference in Asia [mean (SD): 84.1 (13.6) cm] and highest in East Europe [92.5 (15.5) cm]. The proportion of current smokers was on average: 16.2%, lowest in Asia (7.8%) and highest in East Europe (28.5%). Conclusion The high prevalence of CVD risk factors and ASCVD in patients with RA across five world regions shows that there is still an unmet need for vigilance and improved implementation of preventive measures in this high CVD risk patient population. Funding Acknowledgement Type of funding source: Other. Main funding source(s): Lilly

Abstract Objectives Smoking is a major risk factor for the development of both cardiovascular disease (CVD) and RA and may cause attenuated responses to anti-rheumatic treatments. Our aim was to compare disease activity, CVD risk factors and CVD event rates across smoking status in RA patients. Methods Disease characteristics, CVD risk factors and relevant medications were recorded in RA patients without prior CVD from 10 countries (Norway, UK, Netherlands, USA, Sweden, Greece, South Africa, Spain, Canada and Mexico). Information on CVD events was collected. Adjusted analysis of variance, logistic regression and Cox models were applied to compare RA disease activity (DAS28), CVD risk factors and event rates across categories of smoking status. Results Of the 3311 RA patients (1012 former, 887 current and 1412 never smokers), 235 experienced CVD events during a median follow-up of 3.5 years (interquartile range 2.5–6.1). At enrolment, current smokers were more likely to have moderate or high disease activity compared with former and never smokers (P &lt; 0.001 for both). There was a gradient of worsening CVD risk factor profiles (lipoproteins and blood pressure) from never to former to current smokers. Furthermore, former and never smokers had significantly lower CVD event rates compared with current smokers [hazard ratio 0.70 (95% CI 0.51, 0.95), P = 0.02 and 0.48 (0.34, 0.69), P &lt; 0.001, respectively]. The CVD event rates for former and never smokers were comparable. Conclusion Smoking cessation in patients with RA was associated with lower disease activity and improved lipid profiles and was a predictor of reduced rates of CVD events.