“Well, at least it’s nothing serious.” How many rheumatoid patients have heard that, some even from doctors? Last week, after Danita’s story, I wanted to share with you this letter to the editor of Musculoskeletal Network, but health issues and life and a board meeting delayed me.
The letter below is my response to the Musculoskeletal Network article “Cardiovascular Risk in RA Patients: Falling Between the Cracks?” which reported on a new study published in Arthritis Research & Therapy, “Suboptimal cardiovascular risk factor identification and management in patients with rheumatoid arthritis: a cohort analysis.” University of Michigan researchers found that rheumatologists identify and manage cardiovascular risk factors less frequently than primary care doctors do and that even primary care doctors manage CV risk factors less frequently in rheumatoid patients than they do in the general population or in diabetes patients.
As you’ll see below, this has been a known issue for at least a decade.
Musculoskeletal Network reported: “The authors speculate that many rheumatologists overlook cardiovascular issues in their RA patients, assuming (correctly or otherwise) that the PCP is taking care of that. But according to these findings RA patients do not benefit from the same vigilance for CVD risk factors in primary care that is offered for patients who have diabetes.”
Letter to the editor of Musculoskeletal Network, the Journal of Musculoskeletal Medicine
Thank you for the February 8, 2013 article “Cardiovascular Risk in RA Patients: Falling Between the Cracks?”1 Falling through the cracks is a good way to describe a serious issue facing people living with rheumatoid disease: lack of attention with regard to cardiovascular disease (CVD) risk and other serious health threats that result from rheumatoid disease.
Studies have shown rheumatoid patients have a greater CVD risk than can be accounted for with the traditional risk factors mentioned in your article. Therefore, CVD risks tend to be underestimated in rheumatoid patients2. Most rheumatoid patients do not receive a cardiologic workup, despite recommendations of experts such as Sherine Gabriel3 (Mayo Clinic) and studies demonstrating the need for baseline or regular cardiovascular evaluation.4 One study concluded: “Annual CV risk assessment using national guidelines is recommended for all patients with RA and should be considered for all patients with AS and PsA.”5
Furthermore, Rheumatoid patients often need to consult multiple specialists, such as ophthalmologists, pulmonologists, and cardiologists as well as physical therapists or surgeons to manage musculoskeletal issues related to the disease. This is in addition to the excessive level of comorbidity for various problems that require additional care from gastroenterologists, endocrinologists, or spine specialists, for example. However, preventive measures and coordination of care are rarely adequate.
I agree with the researchers’ supposition that many assume primary care physicians manage these issues, and that they usually do not. And, I suggest the following explanations may account for much of the discrepancy that that these researchers recognize and that we see in our community:
- Many assume that the risks are much lower than they are or that when these conditions occur, they are not related to the underlying rheumatoid disease.
- Rheumatologists may not be equipped to identify or treat the several possible systemic manifestations of the disease.
- Years of living with inexplicable symptoms tend to make rheumatoid patients more hesitant to address additional medical problems.
Ten years ago The Journal of Rheumatology reported, “Patients with RA do not receive optimal health maintenance and preventive care services. Efforts should be made, on the part of all physicians who care for RA patients, to ensure that these effective preventive services are provided.”6 We implore the rheumatology community to work together with patients and with the Rheumatoid Patient Foundation to address this crucial issue through expanding medical education and public awareness relating to the systemic nature of rheumatoid disease and establishing of minimal comprehensive care standards.
President, Rheumatoid Patient Foundation
While I appreciate the MN article, I have one further observation about their analysis of the Michigan study. MN wrote: “Rheumatologists may be well aware of the increased risk for cardiovascular disease (CVD) among patients with rheumatoid arthritis (RA), but a recent study suggests that they may be focusing on the rheumatic problem while passing the cardiovascular one to primary care providers (PCPs), who too often are failing to pick up the ball.”
There is a clue here to solving this problem. As long as extra-articular disease is viewed as distinct from “the rheumatic problem,” then rheumatoid patients will not receive adequate medical care. Non-articular aspects of the disease are not “complications” of rheumatoid disease. Statistics and educational resources must be updated to reflect the actual incidence of these issues in rheumatoid patients.
An interesting recent comment from a reader
Tammy: “I believe strongly that the Rheumatologist should be the primary care physician that coordinates all of the care of a person with RA. This is a chronic illness that can have dangers if a person is seeing different docs and taking different meds. Something will fall through the cracks in the care… it always does for me.”
Edit 6/22/13: corrected footnote
- The Mortality Dragon: Do Rheumatoid Arthritis Patients Have to Die Early?
- 3 Reasons to Stop Saying “Complications of Rheumatoid Arthritis”
- Problems with Preventive Care and Rheumatoid Arthritis Mortality
- More Warrior articles tagged “Comprehensive care”
 Musculoskeletal Network. 2013. Cardiovascular Risk in RA Patients: Falling Between the Cracks? Accessed February 14, 2013 http://www.musculoskeletalnetwork.com/rheumatoid-arthritis/content/article/1145622/2127440.
 Kaiser, C., May 29, 2012. Cardio Notes: Heart Risk in RA Miscalculated. MedPage Today. Accessed February 19, 2013 http://www.medpagetoday.com/Cardiology/MyocardialInfarction/32959.
 Science Daily. 2007. Predicting Cardiovascular Disease Risk For Rheumatoid Arthritis Patients. Accessed February 20, 2013 http://www.sciencedaily.com/releases/2007/11/071107181025.htm.
 Desai, S.S., Myles, J.D., and Kaplan, M.J. 2012. Suboptimal cardiovascular risk factor identification and management in patients with rheumatoid arthritis: a cohort analysis. Annals of rheumatic diseases. Accessed February 20, 2013 http://www.ncbi.nlm.nih.gov/pubmed/19773290
 Peters MJ, Symmons DP, McCarey D, Dijkmans BA, Nicola P, Kvien TK, McInnes IB, Haentzschel H, Gonzalez-Gay MA, Provan S, et al. EULAR evidence-based recommendations for cardiovascular risk management in patients with rheumatoid arthritis and other forms of inflammatory arthritis. Annals of the rheumatic diseases 2010 Feb ;69(2):325-31. Accessed February 20, 2013 http://www.ncbi.nlm.nih.gov/pubmed/19773290.
 Kremers, H.M., et al. 2003. Preventive medical services among patients with rheumatoid arthritis. The Journal of Rheumatology. PDF Accessed August 19, 2010 and Abstract accessed February 20, 2013 http://www.jrheum.org/content/30/9/1940.abstract.