A Quality Improvement Project to Facilitate Annual Cardiovascular Disease Risk Assessment in Rheumatoid Arthritis Patients: A Mid-Western Experience
Maria Usman Khan1,3,4, Usman Azhar Khan2,3, Fahd Adeeb1,3, Alwin Sebastian1, Eoghan Maher3, Muddassar Ahmad4, Azhar Abbas4, Mary Brady1, Mary Gillespie1, 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 associated with accelerated atherosclerosis and increased risk of morbidity and mortality from cardiovascular disease (CVD) due to the high prevalence of traditional CVD risk factors (tCVD-RF) and systemic inflammation. EULAR recommends annual cardiovascular risk assessment (CRA) for patients with RA.
To assess the compliance with EULAR recommendations and improvement in CRA we re-audited RA patients at our rheumatology clinics after devising departmental guidelines and continuous education on CRA based on the results from the first audit. The re-audit had same three-fold aims: To determine the prevalence of the tCVD-RF (diabetes, hypertension, hyperlipidemia, long term steroid use and smoking), to assess CVD risk management in RA patients in comparison to the EULAR recommendations, and to identify whether RA disease activity is adequately controlled.
This multicenter study involved 2 teaching hospitals in Mid-West region of Ireland. 100 consecutive patients with definite RA were recruited between May-June 2016 and January-February 2017 in each audit and re-audit phases respectively. A proforma was completed for each patient based on medical notes and electronic record following information at any time since diagnosis of RA: demographic data, disease duration and activity, RF/ACPA status, concomitant ESR & CRP, DAS28, tCVD-RFs, past history of ischemic heart disease (IHD), related co-morbidities (TIA, CVA, PVD, aortic aneurysm) and drug history (current RA, anti-hypertensive and lipid lowering medications). Data on blood pressure (BP), lipid profile and blood glucose (random, fasting or HbA1c) were sought in the preceding 4-years, and if treatment were commenced as per the guidelines. The 10-year risk of fatal CVD was calculated using the Systematic COronary Risk Evaluation (SCORE) chart: total cholesterol/HDL ratio was used & risk was multiplied by 1.5 if patient had 2 of these 3 criteria: disease duration of >10 years, positive RF/ACPA, presence of severe extra-articular manifestations.
Overall results are summarized in Figure 1. There was improvement in the efficiency of recording tCVD-RFs i.e. BMI, smoking, hypertension by 66%, 7% and 4% respectively and better management of hypertension by 9%. 8% patients received smoking cessation advice versus none before. Blood glucose and lipid profiles were well monitored but reduced by 8% and 7% respectively. RA disease activity was adequately controlled with 60% patients in remission in both audits. Due to the lack of required data, only 43 patients had their 10-year CVD risk SCORE model calculated. There was 12% reduction in the moderate risk group to develop fatal CVD within 10-years.
CVD risk management although improved, still remains suboptimal and requires ongoing surveillance. Rheumatologists should actively participate in annual CRA in RA patients to reduce the incidence of IHD.