Utility of the Framingham risk score to predict the presence of coronary atherosclerosis in patients with rheumatoid arthritis

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Abstract

Abstract
The prevalence of ischemic heart disease and atherosclerosis is increased in patients with rheumatoid arthritis (RA). In the general population, but not in patients with systemic lupus erythematosus, the Framingham risk score identifies patients at increased cardiovascular risk and helps determine the need for preventive interventions. We examined the hypothesis that the Framingham score is increased and associated with coronary-artery atherosclerosis in patients with RA. The Framingham score and the 10-year cardiovascular risk were compared among 155 patients with RA (89 with early disease, 66 with long-standing disease) and 85 control subjects. The presence of coronary-artery calcification was determined by electron-beam computed tomography. The Framingham score was compared in patients with RA and control subjects, and the association between the risk score and coronary-artery calcification was examined in patients. Patients with long-standing RA had a higher Framingham score (14 [11 to 18]) (median [interquartile range]) compared to patients with early RA (11 [8 to 14]) or control subjects (12 [7 to 14], P < 0.001). This remained significant after adjustment for age and gender (P = 0.015). Seventy-six patients with RA had coronary calcification; their Framingham risk score was higher (14 [12 to 17]) than that of 79 patients without calcification (10 [5 to 14]) (P < 0.001). Furthermore, a higher Framingham score was associated with a higher calcium score (odds ratio [OR] = 1.20, 95% confidence interval [CI] 1.12 to 1.29, P < 0.001), and the association remained significant after adjustment for age and gender (OR = 1.15, 95% CI 1.02 to 1.29, P = 0.03). In conclusion, a higher Framingham risk score is independently associated with the presence of coronary calcification in patients with RA.

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Introduction
Patients with rheumatoid arthritis (RA) have increased mortality, largely attributable to cardiovascular disease [1], and there is increasing evidence from controlled clinical studies that patients with RA have more extensive extra-coronary atherosclerosis [2-5] and coronary calcification [6] than age- and gender-matched control subjects. The contribution of traditional and novel cardiovascular risk factors has been examined, but the mechanism for this increased cardiovascular risk in RA remains unclear.

Hypertension, smoking, and increased concentrations of C-reactive protein are more frequent in patients with RA than in control subjects [7,8]. Furthermore, patients with RA and coronary-artery atherosclerosis are older and have a higher cumulative exposure to cigarettes and a higher erythrocyte sedimentation rate than patients without atherosclerosis, suggesting that traditional risk factors and inflammation may both play a role in the process [6].

The Framingham risk score is an extensively studied index to predict cardiovascular risk in the general population [9]. It includes age, gender, smoking, blood pressure, and cholesterol concentrations and estimates the risk of coronary events by stratifying individuals into three risk categories: low (<10% risk of an event in 10 years), intermediate (10% to 20%), and high (>20%) [10]. Although the Framingham risk score is widely used in the general population to determine prognosis and the need for intervention [9], the value of this risk score is less clear in younger patients, women, and patients with inflammatory diseases [11,12]. For example, in patients with systemic lupus erythematosus (SLE), another rheumatic disease associated with increased coronary calcification, there were no differences in the Framingham risk score in patients and controls, and the majority of the SLE patients with coronary calcification had a low 10-year risk according to the Framingham calculations [12].

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