Rheumatoid Arthritis Heightens Mortality Risk After CABG, Study Finds

Duration of rheumatoid arthritis and use of corticosteroids were associated with higher risk of adverse outcomes following coronary artery bypass graft (CABG).

Patients with rheumatoid arthritis (RA) who undergo coronary artery bypass graft (CABG) have worse outcomes than patients without the rheumatological condition, according to a new study.

The report, published in Annals of Medicine, adds new evidence to existing concerns about coronary artery disease (CAD) in patients with RA.

Investigators noted that CAD is a major cause of mortality among patients with RA, who also face a higher risk of CAD compared with patients who do not have RA. Existing evidence suggests patients with RA have worse outcomes for percutaneous coronary intervention, but less is known regarding the safety of CABG in patients with RA.

The authors conducted a retrospective analysis of patients within a Finnish national database of hospital admissions and major surgical procedures to see how patients with RA fared vs those who did not have RA. They located 28,249 cases in which patients received CABG for the first time between 2004 and 2014. Patients with previous heart problems or who were unavailable to follow-up were excluded. The remaining patients had RA and underwent first-time CABG (n = 378) or did not have RA but underwent the same procedure (n = 7560). The investigators used propensity-score matching adjustment to compare outcomes in the 2 groups. The median follow-up was 9.7 years.

Overall, the patients had a median age of 67 years, and 21.7% were women. Those with RA had had the disease for a median of 12 years, and 38.4% had used an oral corticosteroid prior to surgery. About 8 in 10 patients with RA were seropositive at the time of the surgery.

At 30 days, 3.7% of patients in the RA group had died vs 2.9% of patients in the control group. In long-term follow-up, the cumulative mortality rate at 14.3 years was 65.5% among patients with RA and 54.4% among those without RA. Patients with RA also had a slightly higher rate of cardiovascular deaths (54.4% vs 53.0%) than the control group.

In addition, patients with RA had higher rates of myocardial infarction (MI). After 1 year, 7.1% of patients with RA had suffered an MI vs 4.7% of the control group. By the 14.3-year follow-up, 39.6% of patients with RA had suffered an MI vs 25.2% in the non-RA group.

The data showed patients who had a longer duration of RA or who used preoperative corticosteroids were at the highest risk of worse mortality. Seropositivity was not independently associated with mortality.

“This study shows that preoperative glucocorticoid usage was a strong predictor of mortality during follow-up,” the authors explained. “Also previous studies have indicated that both cumulative and average daily dose of glucocorticoids [are associated] with increased risk of adverse cardiovascular events and high doses are associated with increased mortality.”

The authors noted limitations to their study, chiefly the retrospective nature, which limited the amount of detailed information on hospitalizations and RA disease activity. Still, they said in combination with other available data, the study findings demonstrate that patients with RA warrant special care when being treated for CAD.

“RA patients might benefit from optimized antirheumatic medication and secondary prevention of cardiovascular disease after CABG,” they concluded.

Reference

Malmberg M, Palomäki A, Sipilä JOT, Rautava P, Gunn J, Kytö V. Long-term outcomes after coronary artery bypass surgery in patients with rheumatoid arthritis. Ann Med. 2021;53(1):1512-1519. doi:10.1080/07853890.2021.1969591