January 02, 2016
Addressing cardiovascular risk in patients with inflammatory diseases
“These are all high inflammatory states that are associated with an increased risk of myocardial infarction and stroke,” says George Farah, MD, Cardiologist, UH Harrington Heart & Vascular Institute; Assistant Professor of Medicine, Case Western Reserve University School of Medicine a cardiologist at University Hospitals Harrington Heart & Vascular Institute. “We know in preclinical and clinical studies that inflammation drives the initiation, progression and complications of atherosclerosis. However, we do not currently have targeted antiinflammatory therapies for atherosclerosis – only the pleiotropic, nonlipid effects of statins.”
To provide more integrated, holistic care for these patients, Dr. Farah and colleagues within the UH Harrington Heart & Vascular Institute are piloting a new program for patients with chronic inflammatory diseases who are over age 45. The initial target is patients with pro-inflammatory conditions, including systemic lupus erythematosus, ankylosing spondylitis, rheumatoid arthritis, Crohn’s disease, ulcerative colitis and psoriasis. The rationale for this program is that inflammation is a marker of increased risk as defined by the JUPITER study, in which patients with normal LDL, but elevated high sensitivity CRP were found to have decreased risk of future cardiovascular death, myocardial infarction and stroke when treated with rosuvastatin compared to placebo. Established risk scores (i.e., Reynolds or ASCVD) and coronary artery calcium scoring are used to stratify patients and initiate preventive strategies based on very low risk (CAC score=0), low risk (CAC score 1 – 99), intermediate risk (CAC score 100 – 399) and high risk (CAC score >400).
“One of the questions is whether anti-inflammatory treatments will reduce the risk of cardiovascular disease in people with inflammatory conditions,” adds UH cardiologist Chris Longenecker, MD, Cardiologist, UH Harrington Heart & Vascular Institute; Assistant Professor of Medicine, Case Western Reserve University School of Medicine. “There may be anti-inflammatory drugs that will reduce risk.”
Dr. Longenecker is employing a similar approach for another group of patients at cardiovascular risk from inflammation – patients with HIV. He runs a twice-monthly cardiometabolic risk clinic, housed where they receive their primary HIV care.
“These patients have a very strong sense of community within their ‘medical home’ and don’t necessarily feel as comfortable traveling outside of their clinic to other providers,” he says. “There’s a comfort level there. Whenever you talk about trying to prevent cardiovascular disease, a lot of it is behavioral change, so you really need to have good relationships.”
Dr. Longenecker typically sees these patients every three to six months. About half have risk factors for cardiovascular disease that he manages with them, but they have no established heart disease. For his patients with established cardiovascular disease, Dr. Longenecker manages the sometimes-tricky interactions between statins and antiretroviral therapy.
“Traditionally, many cardiologists and primary care providers have been worried about the interactions between statins and antiretroviral drugs, so they’ve stayed with the statins that don’t have as many interactions, such as pravastatin,” he says. “That, I think, has set us back because it’s not a very strong statin. Atorvastatin and rosuvastatin are stronger and can be safely prescribed to patients with HIV who are taking antiretroviral drugs.”
Both Dr. Farah and Dr. Longenecker believe the multidisciplinary approach to inflammation will lead to better cardiovascular outcomes for patients, both now and in the future.
“Patients with chronic inflammatory disorders are at increased risk of cardiovascular disease and should be treated aggressively for risk factors,” Dr. Farah says. “However, chronic inflammation contributes to cardiovascular risk in everybody. Two studies testing new antiinflammatory approaches using methotrexate or blocking IL-1 are in the follow-up phase and will report soon whether targeting inflammation can reduce cardiovascular events, even in the general population.”