Category Archives: Heart attack

Rheumatoid arthritis drugs… which ones are friendly to the heart and which ones aren’t!

Rheumatoid arthritis (RA) is a chronic, autoimmune systemic disease which affects approximately two million Americans. While the symptoms that bring the patient to the doctor are the joint swelling and pain, the area of most concern may not be the joints.  It is well established that cardiovascular risk is markedly increased in RA and in fact it is this complication that shortens lifespan by between ten to fifteen years.

A number of clinical studies have retrospectively examined the relationship between certain medications and the risk of cardiovascular events.  The report card has provided some real surprises.heart-attack_0

For example, methotrexate, the workhorse disease modifying anti-rheumatic drug (DMARD) of choice reduces cardiovascular mortality by almost 70 per cent. The mechanism is felt to be due to a reduction of atherosclerotic plaque formation as well as increased clearance of foam cells (Solomon DH, et al. Circulation 2003; 11: 1303-1307).

The other major player in the treatment of RA is the TNF inhibitor group.  These are used in more than 50 per cent of RA patients in the US. These drugs apparently reduce the risk of cardiovascular events by almost 50 per cent (Gonzalaz A, et al. Ann Rheum Dis. 2008; 67: 64-69). Why this occurs is still not clearly understood.

Steroids have been used to treat RA since the early 1950’s.  Steroids have been shown to worsen cardiovascular risk because of their effects on both blood pressure as well as blood glucose.  Steroid use in RA has been associated with increased carotid plaque formation as well as increased arterial stiffness.  So what dose is a safe dose?  The answer is still unknown.

Non-steroidal anti-inflammatory drugs (NSAIDS) raise blood pressure.  Randomized clinical trials have shown that cardiovascular risk is associated with COX-2 inhibitors but also with non-selective COX drugs also.  The upshot? All NSAIDS regardless of class, are associated with increased cardiovascular risk.

Hydroxychloroquine, a drug often used to treat mild RA, is associated with a decrease in diabetes and may also improve lipid status.  Actemra increases lipid profile but the long term effects are still unknown.  Leflunomide (Arava) increases blood pressure.  The eventual effects are still a subject of conjecture.

So what about aspirin?  This medication is used for cardiovascular prophylaxis.  In higher doses it also has anti-inflammatory effects although these are limited by the potential gastrointestinal side effects known to be caused by high dose aspirin. It is well known that other NSAIDS should not be used in patients taking aspirin for cardiovascular prophylaxis since they blunt that effect.

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Rheumatoid arthritis is a cardiovascular risk factor

Rheumatoid arthritis (RA) is associated with a 1.5 fold increase in heart attack, heart failure, and stroke.

While obesity, hypertension,  and diabetes, common associated diseases in RA patients, may play a role, the more likely explanation is the chronic inflammatory process found in RA.

In fact, Joan Bathon, chief of rheumatology at New-York Presbyterian Columbia hearthas published work showing that heart muscle mass is 20% less in RA patients.

Her theory is that RA causes microvascular disease and damage to the heart, much like diabetes does.

Identification of high risk patients is a priority because if these findings prove to be true, it may alter the way RA is managed.

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Fish oil builds strength

A study published in the American Journal of Clinical Nutrition looked at 45 women (average age 64) who completed a 90 day strength training program.

fish-oil-capsules One group was randomized to strength training only;  one group  had strength training plus 2 grams of fish oil daily during training; and one group had strength training plus 2 grams of fish oil daily during and for 60 days before training. All three groups had improved strength but the two fish oil groups had significantly more gains in strength than the strength training group only.

So fish oil is not just good for arthritis and the heart; it’ll make you strong too!

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RA patients shouldn’t stop statins

A study published in the journal Arthritis Care & Research found that RA patients who stopped their statins had a  60% increased risk of dying from heart disease and a 79% risk of dying from all causes compared with RA patients who continued statins.

According to the study authors, even quitting for a short period of time- a few months- increased risk of death.

I’ve had so many patients who have had side effects with these drugs and they ask about stopping them.  This certainly gives pause to that notion.

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Joint replacement surgery associated with heart attack risk

Jim Morelli writing in Arthritis Today commented on a new study published in the Archives of Internal Medicine.

joint-replacement-surgery“We found that total hip and knee replacements substantially increase the risk of heart attack during the first two weeks, in particular in patients older than 60,” says lead study author Arief Lalmohamed, a researcher in the department of pharmaceutical sciences at Utrecht University in the Netherlands. “We learned from this study that we need to focus more on preventing cardiac outcomes following this major surgery.”

The study relied on national registry data on about 95,000 Danish patients who underwent total hip replacement or total knee replacement surgeries between 1998 and 2007. The average age of the hip patients was 72, while the average age of the knee patients was 67. The researchers found that during the two weeks immediately following each surgery, heart attack risk rose sharply – 25-fold for heart-attack-in-hospitalhip patients and 31-fold for knee patients, compared with similar people in the Danish registries who did not have these surgeries.

After two weeks, heart attack risk dropped dramatically – although the overall risk of heart attack after hip replacement surgery remained elevated for six weeks. Researchers also found that the association between hip and knee replacement surgeries and heart attack was strongest in those 80 years or older. They found no significantly increased risk in patients younger than 60.

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Chronic inflammation= BAD NEWS

Laura Landro writing in the Wall Street Journal reported that the final common pathway for many deadly diseases is chronic inflammation. Growing evidence suggests that immune regulation can be altered by obesity, cigarette smoking, and fatty diets.inflammation

The end result could be heart disease, stroke, arthritis, Alzheimer’s disease, cancer, and diabetes. In particular, rheumatoid arthritis has been shown to be associated with a marked increase in cardiovascular events presumably related to chronic inflammation.

obese-manOne striking discovery is that fat cells, particularly those in the abdominal region  “act like small factories to churn out molecules known as cytokines, which set inflammation in motion,” says Peter Libby, chief of the division of cardiovascular medicine at Brigham and Women’s Hospital in Boston and a professor at Harvard Medical School. “We’ve learned that abdominal fat tissue is a hotbed of inflammation that pours out all kinds of inflammatory molecules,” Dr. Libby says.

Blood testing using the C-reactive protein often uncovers the presence of inflammation.

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Gout… a deadly disease!

gout_0Gout is a disease due to the abnormal metabolism governing the conversion of purines to uric acid.  Essentially, uric acid excretion (getting rid of uric acid) can’t keep pace with production.

This condition is reaching epidemic proportions due to the  increasing incidence obese-manof obesity as well as the ever-rising consumption of high-fructose containing beverages.

Gout is not a benign disease because it is part of the “metabolic syndrome.”  This is a collection of medical conditions – called diabetes“co-morbidities”- that seem to cluster around gout.high-blood-pressure

They include diabetes, hypertension, obesity, elevated blood high-cholesterollipids, heart attack, stroke, heart failure, and strokeheart-attackkidney disease.

Treatment of gout is not an option.  It is mandatory!

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