Although not publicly well known, scientists and doctors have known for sometime that rheumatoid arthritis is linked to an increased risk for cardiovascular disease (CVD) including heart attack and stroke. The first person I knew with RA succumbed to heart problems at the age of 62. When his family informed me of his death, they immediately attributed his heart problems to the RA. This incident made me realize the serious nature of the disease long before I was diagnosed.
At the center of the increased CVD risk with RA is something called metabolic syndrome. Metabolic syndrome involves a set of interconnected risk factors that are related to cardiovascular disease and diabetes.1 All of these complex biochemical processes are connected and involve metabolism of food for energy, sugar processing, insulin, insulin resistance, fat/lipids including cholesterols and triglycerides, liver health, food types, excess weight, exercise, and systemic inflammatory responses. Whenever one of the interconnected systems gets out of normal parameters, a cascade of problems may occur which may impact cardiovascular health. In one study, researchers found that 18-49% of RA patients also had metabolic syndrome and this rate was significantly higher than general populations.2These researchers also found that RA patients with higher inflammatory blood markers and those who used corticosteroids were more likely to show signs of metabolic syndrome. Systemic inflammation inherent in rheumatoid arthritis may play a role in the increased CVD risk.3 Anti-inflammatory treatments for RA including DMARDS and many of the biologic treatments like anti-TNFs may impact the biochemical pathways involved in metabolism.4
Metabolic syndrome is characterized by high blood glucose, low HDL cholesterol, high triglycerides, obesity, and hypertension. Up to 39% of RA patients display symptoms of metabolic syndrome placing them at greater risk for cardiovascular diseases. Insulin resistance, when the body produces insulin but does not use it5, is connected with RA, increased inflammation, cardiovascular disease, and type II diabetes.6Insulin resistance is more common in RA patients with higher inflammatory blood markers (c-reactive protein, ESR) and disease activity. The use of biologic treatments that impact inflammatory cytokines, primarily the TNF inhibitors, might benefit those with insulin resistance. For RA patients on TNF inhibitor treatment, improvements were seen in the insulin resistance in multiple studies over the past few years.7
Traditional forms of documenting CVD risk don’t necessarily apply to RA patients, particularly those who are seropositive for rheumatoid factor (RF).8 Traditional predictors of CVD are helpful with RA patients but not sufficient as in general populations. Some researchers call for the development of specific CVD predictors for RA patients as a special population with unique characteristics.9
If you have RA, it is a good idea to pay attention to metabolic systems since you are at an increased risk for insulin resistance, increased inflammation, and cardiovascular disease. Below are some strategies that will likely benefit all RA patients.
- Speak to your rheumatologist about this topic.
- Get your lipids tested. It is important to know LDL levels (“bad” cholesterol), HDL levels (“good” cholesterol), triglycerides, and insulin resistance.
- Watch your diet in terms of refined sugars and starches that rapidly increase blood glucose levels, cause insulin levels to spike, and add stored fat to the midsection. Such a diet increases the chances of developing insulin resistance. This is especially true for RA patients given the inflammatory connections. It is proposed that balancing low fat proteins with whole grain carbohydrates and small amounts of quality fats is the best diet for those with metabolic syndrome In general, a low carb diet is suggested to lower levels of inflammation.10
- Exercise if possible. You don’t need to be a long distance runner or champion body builder. It is believed that muscle resistance exercise is better for insulin resistance as it burns excess glucose in the bloodstream.11
Cardiovascular risk is one extra-articular manifestation of RA that can have serious and fatal consequences. All RA patients and their doctors should be aware of the risk factors, closely monitor CVD related factors, and treat as needed. Ultimately, control of RA and its underlying systemic inflammation should help lower CVD risk. If problems persist, please be proactive by treating and preventing these extra articular symptoms from having a serious impact on your health and life span.