Page 126 - THE EVOLUTION OF EARLY ARTHRITIS AND CARDIOVASCULAR RISK Samina A. Turk

CHAPTER 6
DISCUSSION
Comparison between the Dutch SCORE and Heart SCORE CV risk models revealed a slight agreement between low, medium and high CV risk categories.
According to the Dutch CV-RM guidelines, 30% of the early RA patients had an indication for (adaptations of) preventive treatment at baseline. However, 13% of all the patients had a different indication after four weeks of anti-rheumatic treatment. If baseline CV risk assessment would be applied, this would lead to potential overtreatment in 10% of all the patients.
The risk estimation of the two different CV risk calculators resulted in a significant difference in CV risk score. Clinically this will have an impact on the therapy and prevention strategies chosen, as a patient who is regarded as low risk by one calculator could be classified as high risk by another, and vice versa(7). The Dutch SCORE estimates more patients as high risk, 10 times more often than the Heart SCORE. Overestimating the CV risk can lead to unnecessary treatment, while underestimating may result in CV diseases which could have been prevented. This is partly explained as the Dutch SCORE measures the 10-year risk on CV morbidity and mortality, and the Heart SCORE only assesses the risk on mortality and does not take non-fatal CV events into account(5). However, morbidity can cause functional limitations, therefore it is important for patients and society, and should be taken into account in a CV risk model. In conclusion, it is important to know the limitations of the CV risk calculator which estimated the CV risk of your patient.
CV preventive treatment is proven to be effective, therefore it is important to assess CV risk(25-27). As an increased CV risk is already present in early RA, and might even be present in the preclinical phase, CV risk management should be applied early in the disease course(5;28-32). In the present study, we found that, according to the Dutch SCORE, already 30% of the patients were classified as high CV risk at the onset of RA. However, many patients were classified in a different risk category after the first month of anti-rheumatic treatment. In 13% of the patients, this led to a change in preventive treatment advice. This percentage would probably be lower when applying Heart SCORE, as more patients were calculated as low risk according to this risk model, and so less patients switched from risk category during follow-up. Still, both at baseline and after four weeks of anti-rheumatic treatment many patients needed CV preventive treatment according to the Dutch CV-RM guidelines and did not receive this, reflecting under-treatment, confirming previous reports(33-35).
A higher disease activity was associated with an increased TC:HDL ratio, however the effect of disease activity on the Dutch CV risk SCORE gave inconclusive results. On the one hand, an increase in DAS44 was associated with lower CV risk, but on the other hand, higher ESR and CRP were associated with higher CV risk scores. Because
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