Page 14 - THE EVOLUTION OF EARLY ARTHRITIS AND CARDIOVASCULAR RISK Samina A. Turk

CHAPTER 1
CARDIOVASCULAR RISK
As RA patients have an increased CV risk, CV risk management should be done(45-47). Different CV risk models were developed for the general population to calculate the 10- year risk of CV disease, in which features such as gender, age, smoking status, systolic blood pressure and the total cholesterol: high-density lipoprotein (TC:HDL) ratio are included(48-50). However, many differences between CV risk models have been found and these CV risk models do not adequately predict CV-risk in the RA population(51). In the Netherlands, the Dutch Systemic COronary Risk Evaluation (SCORE) is used in the Dutch CV-risk management guidelines(48;52). The calculated CV risk category (low, medium or high risk obtained with the SCORE), the total cholesterol/HDL ratio, low- density lipoprotein (LDL) and the systolic blood pressure lead to an advice for lifestyle changes and possibly preventive treatment with antihypertensives and/or statins(52). In the Dutch SCORE a correction for RA patients is already taken into account, by adding 15 years to the actual age of a patient(48). However, lifestyle changes and CV preventive medication are naturally not enough to achieve a good result in the treatment of RA patients, the most important part is to suppress the inflammation(53;54).
PATIENT-REPORTED OUTCOMES
As suppressing the inflammation is important to prevent destruction of the joints as well as to lower the risk of CV disease, the treatment goal in RA patients is to attain a state of low disease activity or even remission. This is increasingly achieved with early initiation of targeted anti-rheumatic treatment(5). However, there are several definitions of clinical response and remission and different instruments are used to measure this, which leads to a substantial variation in the proportion of patients classified as being in remission(55;56). In addition, a disagreement between physician- perceived and patient-perceived remission is common(57-60). While the physician often determines remission based on physical examination and laboratory values, patients have a different perspective(61;62). Previous literature identified three main themes of patients’ perspective on remission: 1) reduction or absence of symptoms, 2) reduction of daily impact and, 3) return to normality. The items that are important for patients are not so much the presence of clinical arthritis, but rather pain, fatigue and sleep(63). The reduction in symptoms and impact of the disease on daily life would eventually mean a return to normality. However, the next problem then is the definition of ‘normality’.
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