Adults with rheumatoid arthritis (RA) had a significantly higher risk than do those without RA for developing aortic stenosis (AS), according to a large national cohort of patients.
RA has been associated with an increased risk for ischemic cardiovascular disease, but the association of RA with the risk for AS remains unclear, write Tate M. Johnson, MD, of VA Nebraska-Western Iowa Health Care System, Omaha, and colleagues.
In a study published in JAMA Internal Medicine, the researchers identified 73,070 adults with RA and 639,268 matched control individuals without RA using data from the Veterans Health Administration and Centers for Medicare & Medicaid Services from 2000 to 2019.
The patients and control individuals were predominantly men (about 87%), and most were White (72.3% of patients and 61.7% of control individuals). The mean ages of the patients and control individuals were similar (63.0 vs 61.9, respectively).
The main outcome of incident AS was defined as a composite of inpatient or outpatient AS diagnoses, surgical or transcatheter aortic valve intervention, or AS-related death.
Over a mean follow-up period of 7.9 years in patients with RA and 8.8 years in control individuals, the researchers found 16,109 composite AS outcomes over a period of 6,223,150 person-years, with 2303 that occurred in patients with RA.
The multivariate model adjusted for race, ethnicity, smoking status, body mass index (BMI), rural vs urban residence, comorbidities, and healthcare use.
Overall, RA was associated with an increased risk for the composite AS outcome (hazard ratio, 1.66).
After adjusting for confounders, RA remained associated with an increased risk for composite AS diagnoses, aortic valve intervention, and AS-related death (adjusted hazard ratios, 1.48; 1.34; and 1.26, respectively). Altogether, the incidence of composite AS events was 3.97 per 1000 person-years in patients with RA vs 2.45 per 1,000 person-years in control individuals, with an absolute difference of 1.52 composite AS events per 1,000 person-years.
The results "emphasize that valvular heart disease may be an underrecognized contributor to the persistent [cardiovascular disease (CVD)–related] mortality gap in RA, particularly given the lack of improvement in AS-specific risk over time," the researchers write in their discussion.
Several traditional CVD risk factors (eg, smoking status, diabetes, and coronary artery disease) were not independently associated with AS onset in patients with RA. However, male sex, hypertension, stroke, and other noncoronary CVDs were associated with incident AS in the patients with RA, and increasing age and BMI were associated with stepwise increases in AS risk.
The findings were limited by several factors including the infrequency of AS-related events and consequent modest differences in absolute risk, the researchers note. The predominantly male cohort may limit generalizability of results because RA is more common in women. Other limitations included the predominantly male population and possible misclassification of RA status, they write.
Overall, the results demonstrate an increased risk for AS, AS-related intervention, and AS-related death in people with RA. More research is needed to examine AS and valvular heart disease as potential complications in this population, they conclude.
The study was supported by the Center of Excellence for Suicide Prevention, Joint Department of Veterans Affairs, and Department of Defense Mortality Data Repository National Death Index. Johnson disclosed grants from the Rheumatology Research Foundation during the conduct of the study but had no other financial conflicts to disclose. Other authors disclosed fees and honoraria from pharmaceutical companies outside the submitted work.
JAMA Intern Med. Published online July 31, 2023. Full text
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