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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with rheumatoid arthritis &#40;RA&#41; have a greater prevalence of traditional risk factors and 68&#37; more risk of developing a myocardial infarction<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> than the general population&#44; with this risk persisting even when the analysis is adjusted for traditional coronary risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> EULAR<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> recommendations for the evaluation of cardiovascular risk in subjects with RA propose the application of risk evaluation methods such as&#44; for example&#44; the Framingham type&#46; On the other hand&#44; EULAR recommends special attention to subjects with long-standing RA &#40;over 10 years&#41;&#44; rheumatoid factor or anti-CCP antibody positivity as well as those with extra articular manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Rheumatologists&#44; in their daily clinical practice&#44; must perform different indices&#58; diagnostic&#44; classification&#44; disease activity&#44; radiological progression&#44; risk for fracture due to frailty &#40;FRAX and others&#41;&#44; patient quality of life&#44; etc&#46;&#44; to which we add the evaluation of coronary risk&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2013 ACC&#47;AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults&#58; a report of the American College of Cardiology&#47;American Heart Association Task Force on Practice Guidelines<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> were recently published&#44; which propose &#8220;extensive and consistent&#8221; evidence on the benefit of the use of statins in order to reduce the cardiovascular risk in subjects with LDLc over 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Four groups of patients are identified in subjects who would benefit from the use of statins&#58; &#40;1&#41; subjects with clinical cardiovascular disease&#59; &#40;2&#41; subjects with LDLc&#8805;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; &#40;3&#41; diabetics between 40 and 75 years of age with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and no clinical cardiovascular disease&#44; and &#40;4&#41; subjects with no clinical cardiovascular disease or diabetes&#44; with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and a 10 year estimated risk of &#8805;7&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Because RA has a cardiovascular risk similar to diabetes mellitus&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> that the use of statins provide a modest but significant anti-inflammatory effect&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and that the use of anti-inflammatory drugs &#40;coxibs or non-coxibs&#41; is associated to a greater coronary risk&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> we propose that subjects with RA and no clinical cardiovascular disease&#44; with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and no upper limit for age be considered in group 3 of the four abovementioned groups&#44; which implies the use of statins in &#8220;moderate intensity&#8221;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> for most of the patients with RA&#59; however&#44; in subjects with long-standing RA who are rheumatoid factor&#47;anti-CCP positive or have extra articular manifestations who comply with two or more of these criteria&#44; the clinician might consider the use of &#8220;high intensity&#8221; statin treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These recommendations might be extended to subjects with spondyloarthritis&#44; including psoriatic arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The use of statins modifies the plasma lipid profile and the cardiovascular risk of subjects with inflammatory arthritis in a similar way than in patients without inflammatory arthropathy and this reduction of extended to RA&#44; spondylitis and psoriatic arthritis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; even in subjects with RA who are using statins&#44; the interruption in treatment is associated to an increase in the risk of cardiovascular mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In spite of the benefits in cardiovascular risk that&#44; in our judgment&#44; would be provided by statins in subjects with inflammatory arthritides&#44; the clinician must always take into account the possibility of myopathy and especially liver toxicity that may occur in subjects who frequently take other hepatotoxic drugs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; we recommend that all patients with inflammatory arthritis&#44; especially RA&#44; over 40 years of age&#44; with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and no cardiovascular disease receive statins at a moderate dose and those patients with a particularly high risk &#40;two or more of these conditions&#58; long-standing RA&#44; rheumatoid factor&#47;anti-CCP positivity&#44; extra articular manifestations&#41; receive statins in a high intensity regimen&#46;</p></span>"
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Letter to the Editor
Rheumatoid Arthritis, a New Focus on Cardiovascular Risk
Artritis reumatoide, un nuevo enfoque del riesgo cardiovascular
Erardo Meriño-Ibarra
Corresponding author
erardomerino@gmail.com

Corresponding author.
, Concepción Delgado-Beltrán
Sección de Reumatología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Patients with rheumatoid arthritis &#40;RA&#41; have a greater prevalence of traditional risk factors and 68&#37; more risk of developing a myocardial infarction<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> than the general population&#44; with this risk persisting even when the analysis is adjusted for traditional coronary risk factors&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#44;2</span></a> EULAR<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> recommendations for the evaluation of cardiovascular risk in subjects with RA propose the application of risk evaluation methods such as&#44; for example&#44; the Framingham type&#46; On the other hand&#44; EULAR recommends special attention to subjects with long-standing RA &#40;over 10 years&#41;&#44; rheumatoid factor or anti-CCP antibody positivity as well as those with extra articular manifestations&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Rheumatologists&#44; in their daily clinical practice&#44; must perform different indices&#58; diagnostic&#44; classification&#44; disease activity&#44; radiological progression&#44; risk for fracture due to frailty &#40;FRAX and others&#41;&#44; patient quality of life&#44; etc&#46;&#44; to which we add the evaluation of coronary risk&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The 2013 ACC&#47;AHA Guidelines on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults&#58; a report of the American College of Cardiology&#47;American Heart Association Task Force on Practice Guidelines<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> were recently published&#44; which propose &#8220;extensive and consistent&#8221; evidence on the benefit of the use of statins in order to reduce the cardiovascular risk in subjects with LDLc over 70<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#46; Four groups of patients are identified in subjects who would benefit from the use of statins&#58; &#40;1&#41; subjects with clinical cardiovascular disease&#59; &#40;2&#41; subjects with LDLc&#8805;190<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#59; &#40;3&#41; diabetics between 40 and 75 years of age with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and no clinical cardiovascular disease&#44; and &#40;4&#41; subjects with no clinical cardiovascular disease or diabetes&#44; with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and a 10 year estimated risk of &#8805;7&#46;5&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Because RA has a cardiovascular risk similar to diabetes mellitus&#44;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> that the use of statins provide a modest but significant anti-inflammatory effect&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and that the use of anti-inflammatory drugs &#40;coxibs or non-coxibs&#41; is associated to a greater coronary risk&#44;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> we propose that subjects with RA and no clinical cardiovascular disease&#44; with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and no upper limit for age be considered in group 3 of the four abovementioned groups&#44; which implies the use of statins in &#8220;moderate intensity&#8221;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> for most of the patients with RA&#59; however&#44; in subjects with long-standing RA who are rheumatoid factor&#47;anti-CCP positive or have extra articular manifestations who comply with two or more of these criteria&#44; the clinician might consider the use of &#8220;high intensity&#8221; statin treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> These recommendations might be extended to subjects with spondyloarthritis&#44; including psoriatic arthritis&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The use of statins modifies the plasma lipid profile and the cardiovascular risk of subjects with inflammatory arthritis in a similar way than in patients without inflammatory arthropathy and this reduction of extended to RA&#44; spondylitis and psoriatic arthritis<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a>&#59; even in subjects with RA who are using statins&#44; the interruption in treatment is associated to an increase in the risk of cardiovascular mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In spite of the benefits in cardiovascular risk that&#44; in our judgment&#44; would be provided by statins in subjects with inflammatory arthritides&#44; the clinician must always take into account the possibility of myopathy and especially liver toxicity that may occur in subjects who frequently take other hepatotoxic drugs&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In conclusion&#44; we recommend that all patients with inflammatory arthritis&#44; especially RA&#44; over 40 years of age&#44; with LDLc between 70 and 189<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and no cardiovascular disease receive statins at a moderate dose and those patients with a particularly high risk &#40;two or more of these conditions&#58; long-standing RA&#44; rheumatoid factor&#47;anti-CCP positivity&#44; extra articular manifestations&#41; receive statins in a high intensity regimen&#46;</p></span>"
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Article information
ISSN: 21735743
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