Among health professionals r heumatoid arthritis is understood to be an autoimmune-driven disease of the synovial joints characterised by arthritis, arthralgia and early morning stiffness. What might not be known outside rheumatology circles is the high prevalence of cardiovascular disease (CVD) in this patient cohort. In rheumatoid arthritis, CVD results from a complex process of autoimmune-driven endothelial dysfunction. This in turn causes an acceleration in atherosclerosis of the coronary and cerebral arteries, leading to hypertension, myocardial infarction and stroke.
A meta-analysis conducted by Meune and colleagues pooled data from over 91 000 rheumatoid arthritis patients over a 40-year period anddemonstrated a 60% higher CVD-related mortality compared with the general population (Meune et al, 2009).
Management
In patients with rheumatoid arthritis, regular screening and management of hyperlipidemia, hypertension, diabetes and obesity are vital to mitigate cardiovascular risk. Other variables, such as gender, age, ethnicity, family history and smoking status, also have an impact on an individual's CVD risk estimate.
Rheumatoid arthritis-associated functional disability, extra-articular manifestations and the presence of positive serology (rheumatoid factor or anti-cyclic citrullinated peptides) can further affect CVD-related morbidity and mortality. Consequentially, it is advised to undertake a comprehensive assessment of each patient with rheumatoid arthritis, including all factors associated with CVD risk, to provide an accurate risk profile.
The European League against Rheumatism (EULAR) updated its evidence-based recommendations on managing CVD risk in this patient cohort (Agca et al, 2016). EULAR recommends undertaking a CVD risk assessment at least once every 5 years using a validated CVD tool (such as the SCORE risk calculator (Conroy et al, 2003)), with a 1.5 multiplication factor applied to the results to accurately reflect the impact of inflammation. Adapting the SCORE risk calculator is considered by EULAR to provide the most accurate evidence-based prediction of CVD risk in this patient group.
Management of CVD in rheumatoid arthritis begins with identifying modifiable risk factors individual to each patient. One of the most important is poor diet: maintaining a balanced healthy diet by eating fresh nutrient-rich foods will provide the body with the correct amounts of minerals and vitamins necessary to maintain a healthy lifestyle and reduce CVD risk. Patients should also be advised to avoid highly processed foods and foods high in saturated fats to reduce cholesterol levels.
Regular physical activity and exercise will help patients maintain a healthy weight. It will also help improve joint mobility and reduce stress levels. Advise patients to take up or resume an activity or exercise that they enjoy, either in a group or on their own. They should be advised to make small but impactful changes such as taking the stairs instead of using the lift or getting off the bus a few stops earlier and walking for the rest of their journey. For patients who have mobility issues nurses can facilitate physiotherapy intervention for tailored exercise regimens, graded over time to improve cardiovascular fitness.
Smoking cessation services should be offered to those who require intervention. Patients should be educated about the links between smoking and peripheral vascular disease, cancer, obstructive lung disease, macular degeneration and diabetes. Nurses should offer support and encouragement at every stage in the quitting process by helping patients identify and avoid triggers, and offer tips on how to cope with nicotine withdrawal symptoms. Options of nicotine replacement products can be discussed, such as patches, chewing gum and inhalers, with a view to short-term use. Nicotine receptor medications are also available on prescription. Patients should be advised to speak to their GP or smoking cessation officer about these options.
Medications
Improved management of CVD in rheumatoid arthritis must also be considered in terms of treatment medications. The EULAR guidelines suggest that, if necessary, treatment should follow national guidelines on cardiovascular disease prevention depending on the grade of hypertension and overall risk of CVD by initiating statin therapy and or antihypertensive agents (Agca et al, 2016).
Other medications commonly used in the treatment of rheumatoid arthritis include non-steroidal anti-inflammatory drugs (NSAIDs) and corticosteroids, both of which are associated with an increased risk of CVD. Use of these agents to decrease pain and improve swelling can be life changing for patients with flaring rheumatoid arthritis, so it is important to perform individualised risk/benefit assessments prior to each prescribing episode to justify their use in practice.
Most systemic and biological disease-modifying anti-rheumatic drugs (DMARDs) used frequently to treat rheumatoid arthritis do not affect CVD risk. Indeed, there is some research to suggest that some have cardiovascular protective properties and, in effect, lower CVD risk. However, targeted DMARD agents differ because they have the potential to raise lipid profiles, but regular pre- and post-cholesterol screening can monitor any changes in levels and address issues early in treatment.
Patient education
Patients' awareness and own perceived risk of CVD is poor (Gosh-Swaby and Kuriya, 2019). Reasons for this could be due to an inability by health professionals to translate this information to the patient in a meaningful and relatable way. Barriers to effective patient education in the rheumatology department, eg inappropriate infrastructure, short-staffing, inadequate skill mix and time constraints, could inhibit the ability of health professionals to address CVD risk appropriately, because disease-specific management and interventions will often take precedence in a busy outpatient environment.
Therefore, novel approaches to patient education programmes need to be considered. According to Gosh-Swaby and Kuriya (2019), once patients become aware of the increased CVD risk, they become more engaged with education. However, care needs to be taken with regard to when nurses broach the subject of necessary lifestyle changes to improve CVD risk. It has been reported the optimum time to encourage behaviour change is when the patient is at a stage in their disease when they begin to self-assess their own lifestyle choices and develop the motivation and desire to commit to behaviour change. This time has been described as ‘the golden moment’ (John et al, 2009).
Online-based or e-learning platforms could provide a low-cost high-impact strategy to educate patients on CVD risk at a time that suits them. In practice, the uptake of web-based education could be challenging. However, if this is incorporated into an already existing face-to-face programme using a multimedia approach to learning, such combined implementation may provide a more robust information delivery system and improve knowledge gain.
Research needs to be undertaken into rheumatoid arthritis education, specifically focusing on highlighting CVD risk to examine current methods for effectiveness, sustained knowledge gain and long-term improvements in CVD risk score.
Conclusion
CVD prevention and risk reduction should be an integral component of patient education and disease assessment in rheumatoid arthritis. There are challenges with regard to regular CVD screening in this group—however, nurses can play a pivotal role in advocating for improved CVD assessment and management practices, while supporting patients to make the necessary lifestyle changes such as better dietary choices, smoking cessation and increasing activity levels.
These lifestyle changes will also benefit long-term joint mobility and overall general health for all rheumatoid arthritis patients. Nurse-led research examining the impact of behavioural intervention programmes to improve cardiovascular health should also be explored as part of the rheumatoid arthritis-CVD risk research agenda.