Inflammation May Contribute to Worse Long-Term Survival Rates in People With Rheumatic Disease
Young adults with psoriasis, lupus, and RA face a higher risk of heart attack death, study suggests.
Heart attacks in people under 50 years old are twice as likely to be fatal for people with systemic inflammatory diseases such as psoriasis, rheumatoid arthritis, and lupus, according to a study published in the European Journal of Preventive Cardiology on March 30, 2021.
The findings demonstrate that when a person with one of these inflammatory conditions experiences a heart attack at a young age, they have a higher risk of future adverse cardiovascular events, according to a coauthor of the study,?Brittany Weber, MD, a cardio-rheumatology specialist at Brigham and Women’s Hospital and Harvard Medical School in Boston.
“Inflammatory conditions can occur at any age, but onset is often in young adulthood. It is important that patients with these conditions — and especially those who already have heart disease — should pay close attention to risk factors that are modifiable. This includes lifestyle behaviors, including healthy eating, physical activity, and not smoking, as well as controlling blood pressure, cholesterol, and diabetes,” says Dr. Weber.
Rheumatic Diseases Are Known Contributors to Heart Disease Risk
“These findings confirm what we know from existing literature about rheumatic diseases, and that includes rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, and lupus, higher levels of inflammation in these patients with immune disease produces a higher risk for developing heart disease — typically heart attack and stroke — along with an increased risk for mortality,” says Jonathan Greer, MD, a rheumatologist at Arthritis and Rheumatology Associates of Palm Beach in Florida and medical advisor to CreakyJoints, who was not involved in the research.
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“What’s unique about this research is that it looks at a younger population,” says Dr. Greer. Although in the general population higher cardiac risk is typically associated with older age, people with these inflammatory conditions are at a higher risk regardless of their age, he says. “If you get an inflammatory disease in your twenties, you’re going to be a higher risk for heart disease, and furthermore, you’re going to be at higher risk for dying,” he says.
Recent Spike in Deaths Due to Heart Disease Is Concerning
Although cardiovascular mortality was declining for 10 to 15 years, it has actually started to go up a bit in the past two or three years, according to Eugene Yang, MD, a professor of medicine at the University of Washington in Seattle and the chair of the American College of Cardiology Prevention Section. Dr. Yang was not involved with this research. “There’s a concern that the progress that has been made has reversed itself a little bit,” he says.
The reason why isn’t clear, says Yang. “We’re controlling blood pressure better, cholesterol better, and there’s less tobacco use, but there are things that are going in the wrong direction, including obesity and diabetes,” he says.
Men Are More Likely to Experience Heart Attack at a Young Age
The study used data from the YOUNG-MI registry, a cohort made up of 2,097 people who experienced a heart attack at age 50 or younger between 2000 and 2016 and were treated at Massachusetts General Hospital and Brigham and Women's Hospital in Boston. The participants were 19.2 percent female and 73.3 percent white.
It makes sense that about four out of five heart attacks in the study were experienced by men, says Yang. “Women are much less likely to have heart attacks or heart disease than men at that young age; that is, under 50 years old. We think that’s because of the protective effect of estrogen and progesterone in women who are not menopausal. That’s why typically there’s about a 10-year delay between the onset of heart disease in women compared with men,” he says.
Inflammatory Diseases Affect More Women Than Men
Out of the 2,097 people in the study, there were 53 people with systemic inflammatory disease; 34 people had psoriasis, 12 people had lupus, 5 people had rheumatoid arthritis and 2 people had other conditions.
The women in the study were more likely to have an inflammatory condition than the men, according to the authors. This mirrors the population as a whole. In the United States, men and women are at about equal risk for psoriasis, according to the Centers for Disease Control and Prevention (CDC), but women are about nine times more likely to have lupus and three times more likely to have RA, according to the Lupus Foundation of America and the Arthritis Foundation, respectively.
Higher Levels of Inflammation in People With Immune Disease Ups Risk for Heart Trouble
Women in the study were also more likely to have high blood pressure but had similar rates of high cholesterol and diabetes compared with those without inflammatory diseases.
Inflammation May Be to Blame for Heart Attack Deaths
During a median follow-up of 11.2 years, patients with inflammatory conditions were nearly two times more likely to die than those without inflammatory conditions.
The researchers compared death rates in the 53 patients with inflammatory diseases to a subsample of 138 patients without these conditions. In an effort to zero in on the impact of the inflammatory disease, the two groups were matched for age, sex, as well as known cardiovascular risk factors including diabetes, obesity, smoking, high blood pressure, and high cholesterol. Investigators found that the patients with inflammatory diseases were 2.68 times more likely to die during the follow-up compared with the matched group without inflammatory conditions.
That finding suggests that the worse long-term survival rate in young heart attack patients with inflammatory diseases could be related to inflammation, versus a higher prevalence of other cardiovascular risk factors, according to Weber.
“I think this study increases our existing knowledge that these types of systemic inflammatory diseases carry a great risk of cardiovascular events,” says Yang. “When you have an inflammatory systemic disease, it impacts your blood vessel health and can activate the atherosclerosis process, which then increases the risk of having heart attacks,” he says.
Atherosclerosis is when plaque made up of fatty deposits builds up in your arteries, which can reduce blood flow and lessen the amount of oxygen and nutrients that reach your body, according to the American Heart Association (AHA).
Systemic Inflammatory Diseases Are ‘Risk Enhancers’ for Heart Disease
The 2018 update in guidelines from the American College of Cardiology (ACC) and the AHA says that systemic inflammatory conditions such as lupus, rheumatoid arthritis, and even HIV are “risk enhancers” for cardiac events, according to Yang.
That means these diseases are considered when a doctor is evaluating patients and making decisions about how to manage cholesterol, says Yang. “That may drive a physician to be more aggressive in initiating cholesterol-lowering therapy,” he says.
Although systemic inflammatory diseases aren’t at the level of traditional risk factors such as blood pressure and diabetes, that may change as more data comes out, says Yang. “The strength of the recommendation may increase if we get more evidence to support that,” he adds.
People With Inflammatory Conditions Are Less Likely to Be Prescribed Aspirin or Statins, Research Hints
According to the study authors, aspirin and statins are recommended after a heart attack, but researchers found that in this small sample, the patients with inflammatory conditions were less likely to be prescribed these medications at discharge than those without inflammatory diseases. Although the findings need to be confirmed in a larger study, one potential reason for the finding could be concerns about drug-drug interactions, since these patients often take medications that suppress the immune system, according to Weber.
This is unacceptable, says Greer. “These patients should be treated with the appropriate medication, whether it’s aspirin, a statin, or a beta-blocker, whatever is necessary if they’ve already had one event. If there are any potential drug interactions, that can be worked around.” In general, statins can be used fairly routinely with the biologic drugs; it shouldn’t be an issue, he adds.
Aggressive Treatment Is Needed to Prevent Heart Attacks and Heart Disease in People With Systemic Inflammatory Conditions
“The key takeaway is that we should pay attention to people with these types of comorbidities, even if they don’t necessarily have the traditional risk factors; they may need more aggressive blood pressure and cholesterol treatment,” says Yang.
More Research Is Needed to Know Which Treatments Reduce Risk
The next step is confirming these findings in a larger and more diverse population, says Yang. “We need prospective, randomized studies of patients who have lupus, rheumatoid arthritis, and psoriasis in order to tease out important information, such as whether early intervention with cholesterol-lowering medications or aspirin would help prevent heart attacks and deaths in this population,” he says.
Will Anti-Inflammatory Therapies Lower Heart Risks?
Another important area of current research is trying to uncover whether treating the underlying inflammation with anti-inflammatory therapies lowers the risk of future cardiovascular disease in people with systemic inflammatory conditions, says Weber.
Better tools are needed accurately predict the cardiovascular risk in individuals with inflammatory conditions to help guide preventative therapies, such as statins, she says. “The current calculators, which we use to determine eligibility for preventive medications, generally underestimate the cardiovascular risk in patients with systemic inflammatory disease,” says Weber.