Controlling CVD risk factors is key for people with autoimmune disorders, according to a study published in the Journal of the American Heart Association .
Research Highlights:
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Outcomes after acute coronary syndrome in patients with and without rheumatic immune-mediated inflammatory diseases
Summary
Background
Immune-mediated inflammatory rheumatic diseases ( IMID) are associated with a high risk of acute coronary syndrome. The long-term prognosis of acute coronary syndrome in patients with rheumatic IMID is not well studied.
Methods and Results
We identified Medicare beneficiaries admitted with a primary diagnosis of myocardial infarction (MI) from 2014 to 2019. Outcomes of patients with concomitant rheumatic myocardial infarction and IMID, including systemic lupus erythematosus, rheumatoid arthritis, systemic sclerosis , dermatomyositis or psoriasis, were compared with patients without rheumatic IMID. One-to-three propensity score matching was performed for exact age, sex, race, ST-segment elevation myocardial infarction and non-ST-segment elevation myocardial infarction variables, and greedy approach in other comorbidities.
The primary outcome of the study was all-cause mortality. The study cohort included 1,654,862 patients with a 3.6% prevalence of rheumatic IMIDs, of which the most common was rheumatoid arthritis, followed by systemic lupus erythematosus. Patients with rheumatic IMID were younger, more likely to be female, and more likely to have non-ST segment elevation MI.
Patients with rheumatic IMID were less likely to undergo coronary angiography, percutaneous coronary intervention, or coronary artery bypass grafting.
After propensity score matching, at a median follow-up of 24 months (interquartile range 9–45), the risk of mortality (adjusted hazard ratio [HR], 1.15 [95% CI, 1.14 –1.17]), heart failure (HR, 1.12 [95% CI 1.09–1.14]), recurrent MI (HR, 1.08 [95% CI 1.06–1.11]) and coronary reintervention (HR, 1.06 [95% CI, 1.01–1.13]) (P<0.05 for all) was higher in patients with rheumatic IMID versus without IMID.
Conclusions
Patients with rheumatic MI and IMID have a higher risk of mortality, heart failure, recurrent MI, and need for coronary reintervention during follow-up compared with patients without rheumatic IMID.
Comments
After a heart attack, people with an autoimmune disease were more likely to die, develop heart failure or have a second heart attack compared to people without an autoimmune disease, according to new research.
Autoimmune diseases, such as rheumatoid arthritis, systemic lupus erythematosus, and psoriasis, are known to increase the risk of cardiovascular disease, likely due to multiple factors. People with an autoimmune disease have a higher prevalence of traditional cardiovascular risk factors (such as high blood pressure, type 2 diabetes, or kidney disease), as well as aspects of the autoimmune disease that are also linked to increased cardiovascular risk, such as chronic inflammation , autoimmune antibodies and long-term use of steroid medications. A new study examined whether having an autoimmune disease, compared to not having one, affects a person’s health status after a heart attack.
“The evidence on the risk of adverse events after a heart attack for people with autoimmune disorders is less strong than the evidence for people without these disorders, and mostly from small or single-center studies,” said Amgad Mentias, MD, M. .Sc., senior author of the study and assistant professor of medicine at the Lerner School of Medicine at the Cleveland Clinic in Cleveland. "We conducted our study to examine, in a large cohort, whether there is any difference in the treatment of heart attack patients with autoimmune diseases versus those without, and whether there is a difference in the risk of death, heart failure, heart attack or recurrent myocardial infarctions over time in the long term."
Researchers identified 1,654,862 people in the US aged 65 and older in the Medicare Provider Analysis and Review File (MedPAR) who were admitted to the hospital with a diagnosis of heart attack between 2014 and 2019. MedPAR is a government database of every inpatient bill in the US submitted to Medicare for payment. Of those records, 3.6% (60,072) had an autoimmune disease that causes inflammation noted in their records within the previous year. The most common pathology was rheumatoid arthritis, followed by systemic lupus, psoriasis, systemic sclerosis and myositis/dermatomyositis. They found several important differences between people with and without autoimmune disease who had heart attacks:
- People with an autoimmune disease were slightly younger: The average age was 77.1 years compared to 77.6 years for those without an autoimmune disease.
- The majority of those with an autoimmune disease were women (66.9% vs. 44.2%).
- Those with autoimmune disease were more likely to have had a non-ST elevation myocardial infarction (NSTEMI) (updated from 77.1 to 77.3) (77.3% vs. 74.9%), and were less likely to have having an ST-elevation myocardial infarction (STEMI) myocardial infarction (18.7% vs. 22.1%).
An NSTEMI, the most common type of heart attack recorded in the database, is caused by the partial blockage of one of the coronary arteries that supplies oxygen-rich blood to the heart muscle. A STEMI heart attack, generally more dangerous, is due to a complete blockage of one or more of the heart’s main arteries.
The researchers compared the record of each heart attack patient with autoimmune disease to the records of three heart attack patients without autoimmune disease based on age, sex, race, and type of heart attack. After matching (and excluding people who had not been enrolled in Medicare for at least a year before their heart attack), the researchers compared health outcomes over about 2 years. The final data set included 59,820 heart attack records from people with an autoimmune disorder and 178,547 from people without an autoimmune disorder.
The analysis found that people with an autoimmune disease were:
- 15% more likely to die from any cause;
- 12% more likely to be hospitalized for heart failure;
- 8% more likely to suffer another heart attack; and
- 6% more likely to undergo an additional artery-opening procedure (if they had received it at the time of the heart attack).
“Patients with autoimmune diseases and cardiovascular disorders are preferably managed by a cardiorheumatologist in conjunction with a rheumatologist to optimize cardiovascular health. “Traditional CVD risk factors are accentuated in this population and the way these risk factors manifest is also unique,” said the study’s senior author, Heba Wassif, MD, MPH, assistant professor of medicine at the School of Medicine. Lerner Medicine at the Cleveland Clinic and director of cardiorheumatology. at the Cleveland Clinic.
“For example, cholesterol levels are affected by inflammation, so patients with active inflammatory disease have lower cholesterol levels, a phenomenon known as the lipid paradox,” Wassif said. “Physical activity, which is highly recommended to improve cardiovascular outcomes, may be limited by joint pain. Additionally, some disease-modifying agents may increase cardiovascular risk. Knowledge of these nuances and a team-based approach can improve results.”
The researchers also found that people with an autoimmune disease were less likely to undergo cardiac catheterization to evaluate narrowed coronary arteries or to undergo an artery-opening procedure or bypass surgery, regardless of the type of heart attack.
“It is possible that people with an autoimmune disease were not healthy enough to undergo such procedures, or that their coronary anatomy was less susceptible to interventions to reopen narrow or blocked vessels,” Mentias said. These problems can put them at higher risk for complications related to the procedure. “However, where feasible, if someone is a suitable candidate, these procedures should be considered as options. The presence of an autoimmune disease in itself should not prevent someone from undergoing procedures that could save their life.”
The researchers did not have information about the anatomy of the patients’ coronary arteries, which limited the ability to evaluate whether anatomical differences might have influenced decision-making about vessel-opening procedures. The analysis is also limited by not having laboratory data on the severity and activity of the patients’ autoimmune disease, making it impossible for researchers to evaluate whether the risk of complications and death after a heart attack is higher in patients with severe forms of autoimmune disease compared to those with a milder form or disease in remission.
"Future research is needed on medications and interventions that can reduce the increased risk of poor outcomes in patients with heart attacks and autoimmune diseases," Wassif said, "such as investigating whether different immunomodulators and immunosuppressive therapies used to manage and treat autoimmune disease have "some impact on improving outcomes after a heart attack."
Clinical Perspective
What’s new?
In Medicare patients older than 65 years and a history of rheumatic immune-mediated inflammatory diseases presenting with myocardial infarction, coronary interventions are less used.
Long-term clinical outcomes, including mortality, heart failure, recurrent myocardial infarction, and need for coronary reintervention, were significantly worse compared with patients without immune-mediated inflammatory rheumatic diseases.
What are the clinical implications?
Coronary intervention, aggressive risk factor optimization, and intensification of medical therapy should be offered to patients with immune-mediated inflammatory diseases presenting with myocardial infarction, whenever clinically feasible, to mitigate this elevated risk.
Immune-mediated inflammatory diseases (IMIDs) are chronic conditions characterized by immune dysregulation and inflammation. IMIDs include rheumatoid arthritis (RA), spondyloarthritis spectrum of disease, connective tissue disorders, inflammatory skin conditions such as psoriasis and atopic dermatitis, inflammatory bowel disease, asthma, and autoimmune neurological diseases such as multiple sclerosis.
Specifically, rheumatic IMIDs are associated with multiple cardiovascular manifestations and increased cardiovascular risk, including premature coronary artery disease.
The increased risk of coronary artery disease has been suggested to be multifactorial, including increased prevalence of traditional risk factors, increased chronic inflammatory status, autoimmune antibodies, and increased risk of glucocorticoid use.
In the CANTOS (Canakinumab Anti‐Inflammatory Thrombosis Outcomes Study), canakinumab reduced the risk of major adverse cardiovascular events by 15% compared with placebo.1 The anti‐interleukin‐1β monoclonal antibody reduces inflammation but not blood cholesterol. low density lipoproteins. This indicates the importance of inflammation in the development and spread of atherosclerosis.
Acute myocardial infarction (MI) is associated with a cascade of activation of the immune response, both locally and remotely.
The outcomes of MI in rheumatic IMID patients have been studied in non-contemporary cohorts and the results were not consistent. In a recent nationwide propensity-matched analysis, there was similar in-hospital mortality in rheumatic IMID patients compared with controls. These results contrasted with a previous meta-analysis that showed poor short- and long-term outcomes. The current study aims to examine the management and medium-term outcomes of myocardial infarction in patients with rheumatic IMID versus non-IMID using a contemporary national database.
