类风湿性关节炎可致心梗后死亡风险升高

明尼苏达州罗切斯特市梅奥医院的Sara S. McCoy医生及其同事在对罗切斯特流行病学项目(Rochester Epidemiology Project)数据进行回顾分析时发现，类风湿性关节炎(RA)患者发生心肌梗死(MI)后的长期死亡率显著高于相匹配的无RA的MI患者；RA患者还表现出复发性缺血风险增加(J. Rheumatol. 2013 Feb. 15 [doi:10.3899/jrheum.120941])。

这套分析数据涵盖明尼苏达州Olmsted县所有医务人员提供的病历，分析对象为1979年1月1日~2010年1月1日期间发生MI的77例RA患者和154例年龄和性别相匹配的无RA患者。

总体上，两个队列中的女性均占55%；发生MI时的平均年龄为72.4岁。两个队列在高血压、血脂异常、糖尿病、吸烟状况及肥胖等MI危险因素方面无显著的统计学差异；MI特征、严重度及心电图表现也无组间差异。另外，发生MI期间、MI后30天以及MI后1年，RA患者与对应的无RA患者间在治疗上无差异(5%的RA患者 vs. 8%的对照者，P=0.37)；MI后30天及MI后1年的死亡率亦相近。但长期死亡率不同。RA队列在中位随访2.6年过程中有55人死亡，而对照队列有85例患者在中位随访2.7年过程中死亡。RA患者与无RA患者相比的死亡危险比为1.47[95%置信区间(CI)，1.04~2.08]。将随访时间延长至5年时，结果仍然如此，RA患者的死亡率为57%，而对照组为36%(对数秩检验P=0.036)。RA患者与无RA患者中分别有28例和40例死于心血管原因，尽管在死于心血管原因的病例所占的比例方面无明显的组间差异。复发性缺血在RA患者中也明显多见：5年时，80%的RA患者和50%的对照组患者发生了缺血(对数秩检验的P=0.043)。

本研究因其回顾性设计以及缺乏发生MI时的RA病情活动性数据而有一定的局限性。队列中不足半数患者有发生MI前数月的红细胞沉降率记录，除此之外，在整个研究期间再无其他连续使用或记录的疾病活动性指标。另外，本研究评价死亡率与RA特征之间相关性的检验效能不足。今后还需要进一步研究明确RA患者发生MI后长期结局的决定因素，尤其是RA的特征表现所起的作用。

McCoy医生及其同事无相关的利益冲突披露，其研究获得了国立关节炎骨骼肌皮肤病研究所和国立心肺血液研究所的资助。罗切斯特流行病学项目由国立衰老研究所资助。

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By: DENISE NAPOLI, Cardiology News Digital Network

Rheumatoid arthritis patients had significantly higher long-term mortality after myocardial infarction than did matched MI patients without RA in a review of a population-based cohort of patients.

RA patients also exhibited an increased risk of recurrent ischemia, compared with patients who did not have RA, reported Dr. Sara S. McCoy of the Mayo Clinic, Rochester, Minn., and her colleagues (J. Rheumatol. 2013 Feb. 15 [doi:10.3899/jrheum.120941]).

Dr. McCoy and her coinvestigators analyzed data from the Rochester Epidemiology Project, which includes records from all health care providers for the population of Olmsted County, Minn. They targeted 77 RA patients and 154 age- and sex-matched patients without RA who had an MI between Jan. 1, 1979, and Jan. 1, 2010.

Overall, 55% of patients in both cohorts were female; the mean age at MI was 72.4 years. There were no significant differences between cohorts regarding MI risk factors such as hypertension, dyslipidemia, diabetes, smoking status, and obesity. MI characteristics, severity, and electrocardiogram findings were also similar between groups.

Additionally, RA patients and their unaffected counterparts had no differences in treatment during and after MI and in-hospital mortality (5% of RA patients vs. 8% of controls, P = .37). Mortality at 30 days post MI and at 1 year post MI was also similar.

The similarities ended for long-term mortality. Dr. McCoy and her associates found that during a median follow-up of 2.6 years among the RA cohort, 55 patients died, compared with 85 patients over a median 2.7 years in the control cohort, for a hazard ratio of mortality among RA patients of 1.47, compared with their counterparts (95% confidence interval, 1.04-2.08).

The finding held when extended out to 5 years, with the mortality rate among RA patients at 57%, compared with 36% among controls (log rank P = .036).

"Cardiovascular causes [of death] were found in 28 deaths among patients with RA and in 40 deaths among patients without RA," added the authors, although "there was no apparent difference between groups in the proportion of deaths due to CV causes."

Recurrent ischemia also was more pronounced among the RA patients. At 5 years, 80% of RA patients and 50% of controls had experienced ischemia (log rank P = .043).

The conclusions that can be drawn from the study are limited by its retrospective design, as well as the fact that very few data were collected on RA disease activity at the time of MI.

"Erythrocyte sedimentation rate was documented in less than half the cohort in the months prior to MI, and no other measure of disease activity was consistently used or documented over the study time period," the investigators wrote.

The study also was underpowered to assess any associations between mortality and RA characteristics.

"If RA disease characteristics do indeed play a role in determining long-term survival after MI in persons with RA, this would argue for a more personalized, disease-specific approach to post-MI management for patients with RA, similar to post-MI management in patients with diabetes mellitus," they wrote.

"More research is needed to understand the determinants of long-term outcomes after MI in patients with RA, in particular, the role of RA disease characteristics."

Dr. McCoy and her colleagues disclosed no relevant conflicts of interest. They disclosed funding from the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the National Heart, Lung, and Blood Institute. The Rochester Epidemiology Project is funded by the National Institute on Aging.