N. Erb

Excess recurrent cardiac events in rheumatoid arthritis patients with acute coronary syndrome

Background: Cardiovascular mortality is increased in rheumatoid arthritis. Possible reasons include an increased incidence of ischaemic heart disease or worse outcome after acute coronary syndrome (ACS). Objectives: To assess the outcome of ACS in rheumatoid arthritis compared with case matched controls in the context of underlying cardiac risk factors, clinical presentation, and subsequent management. Methods: 40 patients with rheumatoid arthritis and ACS identified from coronary care admission registers between 1990 and 2000 were case matched as closely as possible for age, sex, classical cardiovascular risk factors, type and severity of ACS, and admission date (±3 months) with 40 controls. A standardised proforma was used for detailed case note review. Results: Age, sex, other cardiovascular risk factors, and type and severity of presenting ACS were not significantly different between cases and controls. Recurrent cardiac events were commoner in rheumatoid arthritis (23/40, 57.5%) than controls (12/40, 30%) (p = 0.013); there were 16/40 deaths in rheumatoid arthritis (40%) v 6/40 (15%) in controls (p = 0.012). Recurrent events occurred earlier in rheumatoid arthritis (log rank survival, p = 0.05). Presentation with chest pain occurred in all controls compared with 33/40 rheumatoid patients (82%) (p = 0.006); collapse occurred in one control (2.5%) v 7/40 rheumatoid patients (17.5%) (p = 0.025). Treatment during the ACS was not significantly different in the two groups. Conclusions: Recurrent ischaemic events and death occur more often after ACS in rheumatoid arthritis. Atypical presentation is commoner in rheumatoid arthritis. There is an urgent need to develop identification and intervention strategies for ACS specific to this high risk group.

Risk assessment for coronary heart disease in rheumatoid arthritis and osteoarthritis

Background: The risk of coronary heart disease (CHD) is increased in rheumatoid arthritis (RA). The reasons for this remain unknown, but traditional risk factors for CHD identified in the general population may be important contributors. Objective: To assess comparatively the prevalence of traditional CHD risk factors and the absolute 10‐year CHD risk in patients with RA or osteoarthritis (OA) without known cardiovascular co‐morbidity. Methods: Consecutive Caucasian hospital outpatients with RA (n=150) or OA (n=100) aged 40–75 years were assessed for known cardiovascular co‐morbidity, age, sex, smoking status, presence of diabetes mellitus (DM), height, weight, systolic blood pressure (BP), total cholesterol (TC) and HDL cholesterol. Absolute 10‐year CHD risk for each individual was calculated using the Joint British Societies CHD risk calculator. Results: Prevalence and distribution of known cardiovascular co‐morbid conditions were similar in RA (56/150, 37%) and OA (34/100, 34%). The resulting subgroups of patients without known co‐morbidity (RA: n=94; OA: n=66) were not significantly different for age, sex, DM, smoking, systolic BP or TC: HDL cholesterol ratio. There was no significant difference in the absolute 10‐year CHD risk between RA and OA (15.6±11.0 versus 14.8±9.3, p=0.63). However, a significant proportion of patients without known cardiovascular disease in both the RA and OA subgroups had a 10‐year CHD risk above the 15% or 30% risk levels, indicating the need for possible or definite intervention respectively. Over 80% of RA patients had at least 1 CHD risk factor that could be modified. Conclusion: Absolute 10‐year CHD risk was not different between RA and OA patients in this study. Substantial numbers of RA and OA patients have potentially modifiable CHD risk factors present. We suggest that CHD risk should be assessed and modifiable risk factors addressed in the routine rheumatology clinic setting.

‘Concealing the Evidence’: The Importance of Appearance Concerns for Patients with Systemic Lupus Erythematosus

Outwardly visible signs associated with systemic lupus erythematosus (SLE) can include facial rashes, alopecia and weight gain. We sought to understand the concerns of SLE patients about their appearance and the recognition of this by healthcare professionals. Semi-structured interviews were carried out with 10 women aged 26-68 years diagnosed with SLE for one to 12 years. Data were analysed with Interpretative Phenomenological Analysis (IPA); this seeks to describe and provide understanding of people’s experience of a phenomenon by studying in-depth a small number from a relatively homogeneous group (women with SLE in the present study). Analysis revealed three themes concerning appearance issues. Participants described public self-consciousness after the onset of SLE. Cosmetics and clothing were used skilfully to appear ‘normal’, hide the ‘self’ and assert control but could increase feelings of difference and isolation. Self-imposed isolation was also described and may relate to depression. The understanding of family, friends, colleagues and healthcare providers was also important. Awareness of the psychosocial concerns of SLE patients with life-changing skin disease may enable multidisciplinary healthcare teams to offer a more sensitive, practical service. The physical and emotional needs of SLE patients need to be ascertained and appropriate educational and psychological services are required.

Obstructive sleep apnoea as a cause of fatigue in ankylosing spondylitis

Fatigue is a common symptom in ankylosing spondylitis (AS) occurring in 65% of patients1,2 and forms part of the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI).3,4 Fatigue has been attributed to sleep disturbance from back pain and stiffness and usually increases with increased disease activity, but can occur independently of AS activity, suggesting the possibility of other causes.1,2 One such cause in the middle aged population is sleep apnoea syndrome (SAS). SAS is defined as 10 or more episodes an hour of airflow interruption for ⩾10 seconds during sleep. It occurs in up to 4% of middle aged people,5 and is associated with increased morbidity and mortality due to higher rates of cardiovascular disease and increased accidents.6,7 We suggest that AS predispose subjects to SAS through several mechanisms, including: restriction of the oropharyngeal airway from temporomandibular joint involvement or cervical spine disease causing pharyngeal and tracheal compression (as has been described in rheumatoid arthritis8); cervical spine disease causing compression …

Cutaneous abnormalities in rheumatoid arthritis compared with non-inflammatory rheumatic conditions

Background: Cutaneous abnormalities are common in rheumatoid arthritis, but exact prevalence estimates are yet to be established. Some abnormalities may be independent and coincidental, whereas others may relate to rheumatoid arthritis or its treatment. Objectives: To determine the exact nature and point prevalence of cutaneous abnormalities in patients with rheumatoid arthritis compared with those in patients with non-inflammatory rheumatic disease. Methods: 349 consecutive outpatients for rheumatology (205 with rheumatoid arthritis and 144 with non-inflammatory rheumatic conditions) were examined for skin and nail signs by a dermatologist. Histories of rheumatology, dermatology, drugs and allergy were noted in detail. Results: Skin abnormalities were reported by more patients with rheumatoid arthritis (61%) than non-inflammatory controls (47%). More patients with rheumatoid arthritis (39%) than controls (10%) attributed their skin abnormality to drugs. Cutaneous abnormalities observed by the dermatologist were also more common in patients with rheumatoid arthritis (76%) than in the group with non-inflammatory disease (60%). Specifically, bruising, athlete’s foot, scars, rheumatoid nodules and vasculitic lesions were more common in patients with rheumatoid arthritis than in controls. The presence of bruising was predicted only by current steroid use. The presence of any other specific cutaneous abnormalities was not predicted by any of the variables assessed. In the whole group, current steroid use and having rheumatoid arthritis were the only important predictors of having any cutaneous abnormality. Conclusions: Self-reported and observed cutaneous abnormalities are more common in patients with rheumatoid arthritis than in controls with non-inflammatory disease. These include cutaneous abnormalities related to side effects of drugs or to rheumatoid arthritis itself and other abnormalities previously believed to be independent but which may be of clinical importance.

Hypertension is not a disease of the left arm: a difficult diagnosis of hypertension in Takayasu's arteritis.

Hypertension and its cause may be missed by failure to measure blood pressure in both arms. We report a case of Takayasu’s arteritis where diagnostic confusion arose because there was a failure to detect a difference in blood pressure between the arms.