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Authors
Abstract(s)
Introdução: A Artrite Reumatóide é uma doença inflamatória, sistémica e crónica que afeta
0,5 a 1% da população mundial. Os doentes com artrite reumatóide apresentam alto risco
cardiovascular - sendo esta a sua principal causa de morte - atribuível a fatores de risco
cardiovasculares clássicos e a fatores de risco associados à patologia (inflamação crónica,
desregulação do sistema imunitário, atividade e severidade da doença, terapêutica da
doença, entre outras). Segundo recomendações da The European League Against
Rheumatism, todos os doentes devem realizar uma avaliação do seu risco cardiovascular, no
entanto não existem escalas de avaliação específicas da artrite reumatóide – uma vez que a
patologia é, por si só, um fator de risco independente - dificultando o seu cumprimento na
prática clínica e colocando em causa o controlo das manifestações cardíacas.
Objetivos: Calcular e comparar o risco cardiovascular obtido através do modelo Systematic
Coronary Risk Evaluation, com o que é obtido através de outras calculadoras – Framingham
Risk Score e o algoritmo desenvolvido pelo American College of Cardiology com a American
Heart Association – em dois grupos de doentes com artrite reumatóide: grupo 1 (sem história
de evento cardiovascular) e grupo 2 (com história de evento cardiovascular), concluindo qual
o que melhor prediz o risco cardiovascular nos doentes com esta patologia.
Métodos: Estudo observacional transversal decorrido entre Setembro de 2019 e Janeiro de
2020, onde foram incluídos doentes que cumpriam os critérios de classificação de Artrite
Reumatóide American College of Rheumatology / European League Against Rheumatism 2010
seguidos na consulta de Reumatologia da Unidade Local de Saúde da Guarda. Os registos
clínicos destes doentes, incluídos na base de dados nacional reuma.pt, foram consultados e
foram recolhidas as seguintes variáveis: idade, sexo, índice de massa corporal, hábitos
tabágicos, história de hipertensão arterial e de dislipidémia, história de diabetes mellitus,
duração da doença, fator reumatóide, anticorpos anti péptido citrulinado cíclico, disease
activity score 28 joints na última consulta, manifestações extra-articulares, história prévia de
eventos cardiovasculares, medicação modificadora da doença e a medicação relacionada com
fatores clássicos de risco. Foi realizado o cálculo do risco cardiovascular individual, usando as
diferentes calculadoras e em ambos os grupos de doentes, e através de testes de capacidade
discriminativa (usando a Receiver Operating Characteristic curve) e de sensibilidade e
especificidade obteve-se uma comparação entre os diferentes modelos estudados. Resultados: Foram incluídos no estudo 107 doentes. O estudo da capacidade discriminativa
revelou resultados razoáveis para todos os cinco modelos avaliados, com áreas sob a curva
entre 0,73 e 0,88. Na análise da sensibilidade e especificidade verificou-se que a calculadora
Systematic Coronary Risk Evaluation não identificou como sendo de alto risco nenhum dos
doentes que registou um evento cardiovascular, no entanto apresentou uma especificidade de
94%. Os melhores índices foram obtidos pelo algoritmo aprovado pela American College of
Cardiology em conjunto com a American Heart Association.
Conclusões: Através deste estudo comprovam-se as limitações das calculadoras de risco
cardiovascular desenhadas para a população geral quando aplicadas aos doentes com artrite
reumatóide, já que não consideram os fatores de risco específicos da doença como fatores de
risco cardiovasculares independentes, subestimando o risco nesta população. Em conclusão, a
avaliação do risco cardiovascular é de extrema importância e não existe ainda uma
calculadora ideal, sensível e específica, e de fácil aplicação na prática clínica.
Introduction: Rheumatoid arthritis is a chronic systemic inflammatory disorder that affects 0,5-1% of the world’s population. Patients with rheumatoid arthritis have a high cardiovascular risk – this being their main cause of death – due to both classic cardiovascular risk factors and risk factors associated with the pathology (chronic inflammation, immune system deregulation, disease activity and severity, disease therapy, etc.). According to The European League Against Rheumatism’s recommendations, all patients should carry out an assessment of their cardiovascular risk, however, there are no specific algorithm’s for rheumatoid arthritis – since the pathology is, in itself, an independent risk factor - making it difficult to comply in clinical practice and calling into question the control of cardiac manifestations. Objectives: To calculate and compare the cardiovascular risk obtained through the Systematic Coronary Risk Evaluation model, with the ones obtained through other calculators - Framingham Risk Score and the algorithm developed by the American College of Cardiology and the American Heart Association - in two groups of patients with rheumatoid arthritis: group 1 (without a history of cardiovascular event) and group 2 (with a history of cardiovascular event), concluding which one best predicts cardiovascular risk in patients with this pathology. Methods: Cross-sectional observational study with data collection between September 2019 and January 2020, included consecutive patients fulfilling 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for rheumatoid arthritis and followed up in the Rheumatology department at Guarda Local Health Unit. Clinical records of these patients, included in the national database reuma.pt, were consulted and the following variables were collected: age, sex, body mass index, smoking, history of arterial hypertension and dyslipidemia, history of diabetes mellitus, duration of the disease, factor rheumatoid, antibodies against cyclic citrullinated peptide, disease activity score 28 joints at the last visit, extra-articular manifestations, previous history of cardiovascular events, disease-modifying drugs and all drugs related to classic risk factors. Individual cardiovascular risk was calculated, using the aforementioned calculators in both groups of patients, discriminative capacity tests (using the Receiver Operating Characteristic curve) and sensitivity and specificity were asserted and the different models were compared. Results: A total of 107 patients were included. The study of discriminative capacity revealed reasonable results for all five models evaluated, with areas under the curve between 0,73 and 0,88. In the analysis of sensitivity and specificity, we found that the Systematic Coronary Risk Evaluation calculator did not identify as being at high risk any of the patients who registered a cardiovascular event, however it presented a specificity of 94%. The best indexes were obtained by the calculator approved by the American College of Cardiology and the American Heart Association. Conclusion: This study proves the limitations of cardiovascular risk calculators designed for the general population when applied to patients with rheumatoid arthritis, since they do not consider the specific risk factors of the disease as independent cardiovascular risk factors, underestimating the risk in this population. In conclusion, cardiovascular risk assessment is extremely important and there is still no ideal calculator, which is both sensitive and specific, and easily applicable in a clinical context.
Introduction: Rheumatoid arthritis is a chronic systemic inflammatory disorder that affects 0,5-1% of the world’s population. Patients with rheumatoid arthritis have a high cardiovascular risk – this being their main cause of death – due to both classic cardiovascular risk factors and risk factors associated with the pathology (chronic inflammation, immune system deregulation, disease activity and severity, disease therapy, etc.). According to The European League Against Rheumatism’s recommendations, all patients should carry out an assessment of their cardiovascular risk, however, there are no specific algorithm’s for rheumatoid arthritis – since the pathology is, in itself, an independent risk factor - making it difficult to comply in clinical practice and calling into question the control of cardiac manifestations. Objectives: To calculate and compare the cardiovascular risk obtained through the Systematic Coronary Risk Evaluation model, with the ones obtained through other calculators - Framingham Risk Score and the algorithm developed by the American College of Cardiology and the American Heart Association - in two groups of patients with rheumatoid arthritis: group 1 (without a history of cardiovascular event) and group 2 (with a history of cardiovascular event), concluding which one best predicts cardiovascular risk in patients with this pathology. Methods: Cross-sectional observational study with data collection between September 2019 and January 2020, included consecutive patients fulfilling 2010 American College of Rheumatology and European League Against Rheumatism classification criteria for rheumatoid arthritis and followed up in the Rheumatology department at Guarda Local Health Unit. Clinical records of these patients, included in the national database reuma.pt, were consulted and the following variables were collected: age, sex, body mass index, smoking, history of arterial hypertension and dyslipidemia, history of diabetes mellitus, duration of the disease, factor rheumatoid, antibodies against cyclic citrullinated peptide, disease activity score 28 joints at the last visit, extra-articular manifestations, previous history of cardiovascular events, disease-modifying drugs and all drugs related to classic risk factors. Individual cardiovascular risk was calculated, using the aforementioned calculators in both groups of patients, discriminative capacity tests (using the Receiver Operating Characteristic curve) and sensitivity and specificity were asserted and the different models were compared. Results: A total of 107 patients were included. The study of discriminative capacity revealed reasonable results for all five models evaluated, with areas under the curve between 0,73 and 0,88. In the analysis of sensitivity and specificity, we found that the Systematic Coronary Risk Evaluation calculator did not identify as being at high risk any of the patients who registered a cardiovascular event, however it presented a specificity of 94%. The best indexes were obtained by the calculator approved by the American College of Cardiology and the American Heart Association. Conclusion: This study proves the limitations of cardiovascular risk calculators designed for the general population when applied to patients with rheumatoid arthritis, since they do not consider the specific risk factors of the disease as independent cardiovascular risk factors, underestimating the risk in this population. In conclusion, cardiovascular risk assessment is extremely important and there is still no ideal calculator, which is both sensitive and specific, and easily applicable in a clinical context.
Description
Keywords
Artrite Reumatóide Avaliação de Risco Calculadoras de Risco Cardiovascular Doença Cardiovascular Risco