Patients with a rheumatic immune-mediated inflammatory disease (IMID) had worse outcomes, especially for mortality, after a myocardial infarction (MI) than those without an IMID, in a large propensity-matched analysis.
At a median of 2 years after their MI, Medicare beneficiaries with an IMID had adjusted risks that were:
15% higher for all-cause death (hazard ratio [HR], 1.15);
12% higher for heart failure (HR, 1.12);
8% higher for recurrent MI (HR, 1.08); and
6% higher risk for coronary reintervention (HR, 1.06; P < .05 for all).
In addition, interventions known to improve outcomes in this context, such as coronary revascularization, were less common in patients with IMID.
“This could be because they usually are sicker and have more risk factors when they present, like kidney disease, so maybe they’re not eligible for the therapy. But by itself, it was surprising they’re not offered these interventions as common[ly] as people who don’t have the disease,” Amgad Mentias, MD, a clinical cardiologist at the Cleveland Clinic, Ohio, told theheart.org | Medscape Cardiology.
The study was published September 14 in the Journal of the American Heart Association, with Mentias as senior author and Heba Wassif, MD, MPH, also with Cleveland Clinic, as first author.
IMIDs, such as rheumatoid arthritis, psoriasis, lupus, and inflammatory bowel disease, are known to be associated with significantly higher cardiovascular disease (CVD) risk due to a greater prevalence of traditional CVD risk factors and chronic systemic inflammation.
Certain disease-modifying agents may also increase patients’ cardiovascular risk. This has been a long-simmering issue for the arthritis and ulcerative colitis drug tofacitinib (Xeljanz, Xeljanz XR), resulting in an updated black box warning in 2021.
Many of these patients also have joint disease, pain, and fatigue, which can limit physical activity, Mentias said. “So these small nuances of how to manage these patients, or balance between controlling the inflammation but also improv[ing] cardiac risk factors, is not an easy task.”
Evidence regarding post-MI events has been inconsistent and limited to smaller single-center studies, he said. After propensity-score matching, the present study included 59,820 patients with and 178,547 patients without rheumatic IMIDs followed for a maximum of 6 years.
They were drawn from a cohort of 1.6 million persons aged 65 or older in the Medicare Provider Analysis and Review (MedPAR) file who had been admitted for an MI between 2014 and 2019. Of these, 60,072 had a prior history of rheumatic IMIDs, most commonly rheumatoid arthritis (77.8%), followed by systemic lupus erythematosus (12.2%), psoriasis (5.1%), systemic sclerosis (2.8%), and myositis/dermatomyositis (1.8%).
Patients with an IMID were more often women; had a higher prevalence of valve disease, pulmonary hypertension, hypothyroidism, and anemia; and were more likely to present with non–ST-segment MI (NSTEMI).
Rates of coronary angiography (46.1% vs 51.5%), percutaneous coronary intervention (31.6% vs 33.6%), and coronary artery bypass grafting (7.7% vs 10.7%) were significantly lower in patients with IMIDs who had NSTEMI compared with patients without an IMID who had NSTEMI. Rates of these interventions were also lower in patients with IMIDs who presented with STEMI vs their peers without an IMID, at 78.2% vs 80.7%, 70.2% vs 71.5%, and 4.9% vs 6.4%, respectively.
Mentias pointed out that the emerging subspecialty of cardiorheumatology is gaining traction, especially at large hospitals and academic centers, but that less than one third of persons in the US with an IMID are likely to be under the care of such specialists.
“It’s important before developing an MI to try and control the different risk factors and improve the risk profile for these patients as much as possible by both specialties and, then after an unfortunate event like MI happens, it’s important to make sure we offer therapies and treatments that are known to improve outcomes,” he said.
Commenting to theheart.org | Medscape Cardiology, Jon Tyler Giles, MD, a clinical researcher who focuses on cardiovascular diseases in rheumatology at Columbia University Vagelos College of Physicians and Surgeons in New York City, said that “at least for rheumatoid arthritis, this is something that we already knew. People with rheumatic arthritis, when they have a heart attack, are less likely to get the standard kind of treatments and have worse outcomes. This is a little larger sample, but it’s not a surprise, not a surprise at all.”
He noted that the study could have answered questions regarding potential drivers, but “they didn’t dig down into any of the factors that were associated with the poorer outcomes in the patients with rheumatoid arthritis and lupus and scleroderma.”
Indeed, the investigators acknowledge that the study lacked information on coronary anatomy, duration and severity of the autoimmune disease, imaging data, and medications such as anti-inflammatory or immune-targeted therapies.
Giles highlighted several factors that can contribute to a poorer post-MI prognosis in patients with rheumatic diseases; these include frailty, being more hypercoaguable, increased rates of myocardial dysfunction and other heart and blood vessel diseases, and chronic treatment with steroids and nonsteroidal anti-inflammatory drugs that often interferes with anticoagulation after a MI or when putting in a stent. “So, there’s lot of moving parts and not one single thing that is likely the answer.”
In addition, he said, “there’s always going to be a portion of these patients who, despite doing the best that we can with treatment, are going to have very severe disease. That may or may not be the subset of patients that did the worst, but likely they’re over-represented in those patients.”
Finally, the inability to move the needle may lie with the lack of evidence-based screening and management guidelines for cardiovascular disease in any rheumatic disease, Giles observed. “There’s no guideline for us to use to decide who needs screening over and above what’s recommended for the general population, and then even if you do screen, what do you do other than what you would normally?”
Rheumatologists are often reluctant to take up the cardiovascular screening side of thing because visits are short and a lot of that time is spent trying to manage the inflammatory components of a patient’s disease, he said. There’s also a barrier in getting some patients to add a cardiologist to the mix of physicians they already see, especially if they don’t have any symptoms.
“If someone has had an event, it’s a lot easier for people to be convinced to go see the cardiologist obviously, but prior to having an event, the preventative side of things is something that often gets missed or goes to the wayside,” Giles said.
The study was partly funded by philanthropic gifts by the Haslam family, Bailey family, and Khouri family to the Cleveland Clinic for coauthor Dr Milind Desai’s research. Desai is a consultant for Medtronic and Bristol Myers Squibb and serves on an executive steering committee of a BMS-sponsored trial. The remaining authors report having no relevant disclosures. Giles is a consultant on drug cardiovascular safety for Pfizer, AbbVie, and Eli Lilly.
J Am Heart Assoc. Published online September 14, 2022. Full text