Page 15 - THE EVOLUTION OF EARLY ARTHRITIS AND CARDIOVASCULAR RISK Samina A. Turk

AIM AND OUTLINE OF THIS THESIS
This thesis is devoted to the early phase of RA, focusing on three areas: disease development, cardiovascular comorbidity and remission from the perspective of the patient.
Part I is divided in two chapters wherein the at risk phase of RA is reviewed, to understand the processes in the preclinical phase that lead to the development of clinical arthritis. Chapter 2 focuses on the risk factors for the development of RA and how different risk factors are combined in risk models for the prediction of RA. Chapter 3 updates the risk factors for developing RA and focuses on the transition between ‘early RA’ and ‘established RA’. Finally, interventions to prevent the transition from the at-risk phase to clinical arthritis as well as from undifferentiated arthritis to RA, were reviewed.
With the evolution of RA, a systemic disease, extra-articular manifestations can develop as well. In Part II the focus is on CV disease, the major comorbid condition in early RA patients. The studies that are described in these three chapters were performed in patients of the early arthritis clinic (EAC) at Reade (formerly the Jan van Breemen Institute). This ongoing observational cohort started in 1995 and includes patients with at least one swollen joint, a short duration and no prior treatment with disease-modifying antirheumatic drugs (DMARDs). In this cohort questionnaires were completed, physical examinations were performed, radiographs were taken and blood was obtained. After 2008 CV measurements were added to traditional RA measurements, such as an electrocardiogram (ECG), ankle-brachial index (ABI) measurement, lipid profile and (whole body) DXA-scans. As an unfavorable body composition is a risk factor for both CV disease and the development of clinical arthritis, we compared body composition between patients at the clinical onset of arthritis with the general population in chapter 4, to determine if an unfavorable body composition is already present at the onset of arthritis. Furthermore, as RA patients have a greater risk of sudden cardiac death, we determined the prevalence of conduction disorders and traditional CV risk factors in chapter 5. The final section of this part is about CV risk prediction. As atherosclerosis is the leading cause of death in RA patients, prevention of a CV disease is very important. Different CV risk prediction models exist, which determine if lifestyle changes or preventive treatment for CV diseases are necessary. However, it is unknown when in the course of RA CV risk management should be applied and which risk model should be used. Therefore, in chapter 6 we studied if there are changes in CV risk and CV risk prevention advices between risk models and before and after one month of anti- rheumatic treatment.
The effect of modern anti-rheumatic treatment on disease activity is described in Part III, with a focus on patient-reported outcomes (PROs). Disagreement between definitions of response and remission as well as disagreement about remission between physician and patient is common. In chapter 7 we determined the frequency of patients that
GENERAL INTRODUCTION 1
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