Indications for Lowering LDL Cholesterol in Rheumatoid Arthritis: An Unrecognized Problem
Maria Usman Khan1,3,4, Usman Azhar Khan2,3, Alwin Sebastian1, Fahd Adeeb1,3, Eoghan Maher3, Hafiz Hamid Bajwa4, Muddassar Ahmad4, Mary Brady1, Siobhan Morrisey1, John Paul Doran1, Joseph Devlin1, Alexander Fraser1,3 preprocess
1. Department of Rheumatology, University Hospital Limerick, Limerick, Ireland 2. Department of Cardiology, University Hospital Limerick, Limerick, Ireland 3. Graduate Entry Medical School, University of Limerick, Limerick, Ireland 4. Department of Rheumatology, Beaumont Hospital, Dublin, Ireland
Rheumatoid arthritis (RA) is a recognized independent risk factor of accelerated atherosclerosis. The 2016 Joint European Society of Cardiology (ESC) guidelines on cardiovascular disease (CVD) prevention in clinical practice recommended a systematic CVD assessment as a screening tool in individuals at increased cardiovascular risk including targeted high-risk subpopulation such as RA, using the Systematic COronary Risk Evaluation (SCORE) tool that gives an estimate of the 10-year risk of a first fatal atherosclerotic event.
The aim of the study is twofold: To determine the efficiency of screening for hyperlipidemia in our RA cohort and secondly, to evaluate the initiation and optimization of lipid lowering therapy among the indicated RA patients after devising departmental guidelines and continuous education based on the initial results of first audit in June 2016.
This multicenter re-audit involved 2 teaching hospitals (Croom hospital & University Hospital Limerick). 100 consecutive patients with definite RA were recruited in January-February 2017. A proforma was completed for each patient based on medical notes and electronic record. In those patients where data on age, gender, smoking, blood pressure and lipid profile were complete, the 10-year risk of fatal CVD was calculated by using the SCORE chart. The patients were stratified into 4 risk categories, and together with measurement of target LDL-cholesterol (LDL-c) levels, recommendations for lipid lowering measures were adapted: Ideal LDL-c for low (SCORE <1%) and moderate risk patients (SCORE ≥1- <5%) should be <3.0 mmol/L, <2.6mmol/L for high risk (SCORE ≥5- <10%) and <1.8mmol/L for very high risk patients (SCORE ≥10%). Statins were the recommended treatment.
Among the 100 patients, full lipid profile was performed in 80% patients within the last 4-years as compared to 87% patients in first audit. In both studies 43% patients had adequate data to calculate the 10-year risk of fatal CVD. Figure-1 illustrates 10-year CVD risk based on SCORE model stratifying patients in 4 risk categories on the basis of target LDL-c and also compares patients in these categories in both audits. We found that overall there was 5% improvement in lipidaemic control indicating optimized statin dose and 14% patients achieved their target LDL-c while on treatment. Overall 41% patients (18/43) had an indication for de novo statin therapy in both audits as they were not on treatment despite fulfilling the above-mentioned criteria.
Despite sufficiently having adequate indication to be on lipid lowering therapy, majority of the patients remained untreated. To address this issue, we recommend further education both at departmental and community level and annual screening using the latest Joint ESC guidelines of the 10-year risk of fatal CVD in combination with target LDL-c measurement, with re-audit to see if this is achieved.