It wasn’t enough to cause a lot of pain, swelling in the joints and the feeling of waking up with some of them stiff and rusty, rheumatoid arthritis leaves the heart under severe threat.
So far, for those who deal with this autoimmune disease, there is nothing new. It is already known that it is capable of increasing the risk of someone having a heart attack by two to three times — and of suffering a stroke (cerebrovascular accident), too, I want to remind you.
And this, attention, even if the person does not have any other traditional cardiovascular risk factor, such as diabetes, sedentary lifestyle, smoking, high blood pressure? Having rheumatoid arthritis is enough to triple the likelihood of even sudden death.
Faced with this reality, rheumatologists do what they can. It is worth taking the opportunity to clarify: they are the specialists that we should look for when we have any problems with connective tissues, such as joints.
Every six months at the most, these physicians usually reassess the cardiovascular health of their patients with rheumatoid arthritis. They measure blood glucose and cholesterol, measure blood pressure, use scores to calculate the risk of such a scare. And yet?
“And yet, despite all this care, cardiovascular disease remains by far the main cause of death among those with rheumatoid arthritis”, notes rheumatologist Nathália Sacilotto. “Aren’t we missing something? Could it be that we didn’t have anything else to do?”
A doctor at Iamspe (Institute for Medical Assistance to State Civil Servants), in São Paulo, this question led her to conduct a study with her colleagues. He yielded an article in Journal of Clinical Rheumatology, publication of the Pan American League of Rheumatology Associations.
The research proposes that, from now on, doctors improve the follow-up routine of those with rheumatoid arthritis, periodically including ultrasound with doppleran exam that allows you to see blood flow in real time.
This ultrasound, in turn, would not only be performed on the carotid artery, the artery that rises through the neck and takes oxygenated blood to the brain, but also on the femoral artery, which passes through the thigh, irrigating the lower limbs.
Because, although all 70 women in the Iamspe study were considered at low cardiovascular risk according to the assessment score that rheumatologists usually use, no less than 81% of those who had rheumatoid arthritis, which would be half of the sample, hid plaques of fat in the femoral artery. It was quite a bad surprise.
Femoral versus carotid
“Scientific literature has been pointing out that, even without rheumatoid arthritis, femoral plaques are capable of making a person three times more likely to have a heart attack than someone who does not have these same plaques. It is a stronger association than the one we found by examining the carotid artery”, says doctor Nathália, justifying why she decided to look at this artery and why the result of her study draws the attention of the rheumatologist community.
In those women in the research, the leg arteries also had thicker walls than normal. This, added to the plaques, narrowed the passage for blood flow, which would favor the appearance of thrombi, or clots. Understand: this finding can mean a time bomb for the chest or for the brain.
If the same ultrasound was performed with doppler in the carotid artery alone, the drama capable of triggering a heart attack or stroke could remain invisible: a smaller proportion of participants with rheumatoid arthritis, that is, only 31% of them, showed alterations in this artery.
“The result reveals that the methods used to assess the general population, which until now do not look at the femoral artery, may fail in those with rheumatoid arthritis”, says doctor Nathália. “That way, we end up not getting patients who have a subclinical disease, that is, without manifestations that would be detected in traditional follow-up.”
The link to cardiovascular disease
Without science knowing exactly the reasons, the defense cells of those with rheumatoid arthritis decide to attack the very thin membrane that covers the joints.
This happens twice as often in women as in men, and the first signs of attacks often appear between the ages of 30 and 50. Hands, wrists, elbows, knees, ankles and shoulders are the most affected joints. They turn red, swell and, early in the morning, seem to freeze. Over time, if nothing is done to control the attacks of the immune system, deformities appear in the injured joints.
During all this war between the body and itself, the endothelium, which is the inner lining of the vessels, is also suffering damage, but in silence. “The inflammatory substances produced by rheumatoid arthritis injure this tissue”, explains doctor Nathália. “And the injuries, in turn, facilitate the development of fatty plaques.”
How was the risk calculated?
In the general population, physicians use certain scores to assess the likelihood of a cardiovascular event. One of them, a true cardiology classic, is the so-called score of Framingham, which considers sex, age, if the individual has hypertension, if he has diabetes, if he smokes and other factors to estimate the risk of having a heart attack, for example, in the next ten years.
In the case of those with rheumatoid arthritis, however, following the guidelines of the European League Against Rheumatism — as Nathália and her colleagues did — , the result of the score of Framingham must be multiplied by 1.5. Precisely because of the inflammation catching fire in the vessels.
Still, it’s worth noting that the women in the study would have a low risk. Apparently. Even with this multiplication and taking into account that they did not have active rheumatoid arthritis. That is, they were controlling the autoimmune disease very well with medication, they did not have swelling, intense pain, morning stiffness for more than an hour and blood markers indicating high inflammation. “If the disease were active, of course the cardiovascular risk would be greater”, says doctor Nathália.
And if that were the case, maybe the doctors would order the ultrasound with doppler of the carotid artery — well, many cardiologists and rheumatologists already request this exam. But it was the femoral artery that revealed a greater risk than all estimates, so far, would indicate.
To protect yourself from threats
Lifestyle adjustments are mandatory for those with rheumatoid arthritis to prevent artery problems. You know what I’m talking about: a balanced diet, good sleep, physical activity?
Putting out the cigarette is something that deserves to be underlined. “Smoking triggers rheumatoid arthritis in people with a tendency to have this disease and also makes it more severe”, warns the rheumatologist from Iampse.
This whole package, however, is of no use when there are already plaques in the carotid artery —and now, as it turned out, in the femoral artery. Then, the rheumatologists need to introduce drugs to lower cholesterol and prevent clots, often referring the case to a fellow cardiologist.
And, in this sense, the message of the study is accurate: those who have rheumatoid arthritis need to always check the state of their arteries, no matter how much the joints stop complaining thanks to the treatment.
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