Arthritis & Rheumatism, Volume 62,
November 2010 Abstract Supplement

Abstracts of the American College of
Rheumatology/Association of Rheumatology Health Professionals
Annual Scientific Meeting
Atlanta, Georgia November 6-11, 2010.


Rheumatoid Arthritis Patients Receive Less Frequent Acute Reperfusion and Secondary Prevention after Myocardial Infarction.

Van Doornum4,  Sharon, Brand3,  Caroline, Sundararajan1,  Vijaya, Ajani3,  Andrew, Wicks2,  Ian

Monash University
Royal Melbourne Hospital, Melbourne, Australia
Royal Melbourne Hospital
University of Melbourne, Victoria, Australia

Introduction:

The 30-day case fatality rate after acute myocardial infarction (MI) for rheumatoid arthritis (RA) patients is twice that of the general population.1 This study compared the frequency and timeliness of early reperfusion therapy and treatment with secondary prevention medications after acute MI in RA patients and controls.

Methods:

We performed a structured medical chart review of RA patients and matched controls who had been admitted with acute MI to one of three hospitals in Victoria, Australia between 1995 and 2005. The administration and timing of acute reperfusion therapy and in-hospital treatment with secondary prevention medications was compared between the two groups. Acute reperfusion was defined as thrombolysis or percutaneous coronary intervention (PCI) within 12 hours of first symptom of MI.

Results:

The medical charts of 90 RA patients and 90 matched controls were reviewed. Demographic details, cardiovascular risk factors and other co-morbidities of the RA and control patients are shown in Table 1.

Table 1. Demographic and clinical features of the RA and control patients acute MI

 RA (n = 90)Controls (n = 90)
Female, n (%)55 (61)55 (61)
Age in years, mean (SD)71 (10)71 (10)
RA disease duration in years, mean (SD)20 (13)
No. of DMARDs, mean (SD)1.4 (1.1)
Taking NSAID at time of MI, n (%)21 (23)6 (7)*
Pre-existing co-morbidities:  
Ischemic heart disease, n (%)31 (34)33 (37)
Prior MI, n (%)10 (11)11 (12)
Non-cardiac vascular disease, n (%)26 (29)14 (15)*
IDDM, n (%)3 (3)1 (1)
NIDDM, n (%)22 (24)27 (30)
Hypertension, n (%)52 (58)56 (62)
Hypercholesterolaemia, n (%)22 (24)38 (42)*
Current smoker, n (%)14 (15)16 (18)
Congestive cardiac failure, n (%)15 (17)11 (12)
Chronic lung disease, n (%)28 (31)16 (18)
Chronic renal impairment, n (%)15 (17)8 (9)
*p < 0.05

Table 1 shows the treatment received by the RA and control patients after acute MI. The RA patients were significantly less likely to receive acute reperfusion compared with the controls (16% vs 37%: OR 0.27 (95% CI 0.10–0.64)), and this difference persisted after adjusting for type of MI, clinical setting of MI and prior MI (OR 0.2, 95% CI 0.05–0.6).

Table 2. Treatment received by RA and control patients following MI

 RA (n = 90)Controls (n = 90)  
 n%n%Unadjusted OR§ (95% CI)Adjusted OR¶ (95% CI)
Acute reperfusion*141633370.27 (0.10–0.64)0.21 (0.07–0.62)
Thrombolysis8922240.30 (0.10–0.77)0.33 (0.11–0.96)
PCI101130330.20 (0.06–0.53)0.23 (0.09–0.63)
PCA394352580.41 (0.16–0.92)0.54 (0.23–1.25)
CABGS111217190.57 (0.21–1.46)0.67 (0.27–1.65)
§McNemar's chi-squared test;¶Conditional logistic regression, adjusting for type of MI (STEMI or NSTEMI), presence of prior MI and clinical setting of MI; PCI percutaneous coronary intervention (angioplasty ± insertion of stent); PCA percutaneous coronary angiography; CABGS coronary artery bypass graft surgery.

Urgent reperfusion is not necessarily indicated in all cases of MI, however in the event of STEMI early thrombolysis or PCI is considered the standard of care. Of the total study cohort, 29 of the RA patients and 39 of the controls were diagnosed with STEMI. Acute reperfusion was administered in 48% of the RA-STEMI patients versus 74% of the control-STEMI patients (p=0.027).

Table 3 shows the number of RA and control patients who received treatment with selected secondary prevention medications after MI. The RA patients received less frequent in-hospital treatment with beta blockers (71% vs 83%: OR 0.42 (95% CI 0.18–0.96)) and lipid-lowering agents (40% vs 70%: OR 0.21 (95% CI 0.09–0.46)).

Table 3. In-hospital treatment with secondary prevention medications received by RA and control patients following myocardial infarction

 RA (n = 90)Controls (n = 90) 
 n%n%OR§ (95% CI)
Aspirin859489990.20 (0.02–1.71)
Beta Blockers647175830.42 (0.18–0.96)
ACE Inhibitors616857631.18 (0.67–2.08)
Lipid-lowering agents364063700.21 (0.09–0.46)
§McNemar's chi-squared test; PCI percutaneous coronary intervention; PCA percutaneous coronary angiography; CABGS coronary artery bypass graft Surgery   

Conclusions:

RA patients who experience acute MI receive acute reperfusion and secondary prevention medications less frequently than controls. This may contribute to higher case fatality rates after MI in RA patients.

1Van Doornum, S et al. Arthritis Rheum 2006;54(7):2061–8

To cite this abstract, please use the following information:
Van Doornum, Sharon, Brand, Caroline, Sundararajan, Vijaya, Ajani, Andrew, Wicks, Ian; Rheumatoid Arthritis Patients Receive Less Frequent Acute Reperfusion and Secondary Prevention after Myocardial Infarction. [abstract]. Arthritis Rheum 2010;62 Suppl 10 :1052
DOI: 10.1002/art.28819

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