부산대학교 도서관

BACKGROUND: Risk of cardiovascular disease is increased in patients with rheumatoid arthritis (RA), although the reasons for this increase are not clear. Disease-modifying antirheumatic drugs (DMARDs) can affect cardiovascular disease risk in patients with RA by directly affecting athero-sclerosis through inflammation or by influencing cardiovascular risk factors. OBJECTIVE: The objective of this study was to investigate whether treatment with conventional DMARDs is associated with cardiovascular disease in patients with RA. DESIGN AND INTERVENTION: This was a case-control study that included patients who fulfilled the American College of Rheumatology criteria for RA and who were receiving treatment with conventional DMARDs: sulfasalazine, hydroxychloroquine and methotrexate. Patients were separated into groups according to DMARD use: sulfasalazine, hydroxychloroquine, methotrexate monotherapy, combination therapy with two or three of these drugs, or no past treatment with any of the studied DMARDs. Data analysis included comparisons between each DMARD treatment group and between patients with and without cardiovascular disease (defined as coronary, cerebral or peripheral arterial disease). Three correction models were used for the data analysis: data corrected for age, gender, smoking history and duration of RA; data corrected for hypertension, diabetes and hypercholesterolemia; and data corrected for presence of rheumatoid factor and radiographically visible joint erosions. The study period was defined as time from first diagnosis of RA until occurrence of the first cardiovascular event or the end of the follow-up period. OUTCOME MEASURES: The primary outcome measure of this study was the occurrence of a cardiovascular event. RESULTS: Data from a total of 613 patients with RA were included in this study. Overall, 72 patients developed cardiovascular disease during the study period, and 541 patients did not. Treatment with methotrexate, either alone or in combination with sulfasalazine or in combination with sulfasalazine and hydroxychloroquine, was associated with a significantly decreased risk of cardiovascular disease compared with no DMARD treatment; odds ratios were 0.16 (95% CI 0.04-0.66), 0.20 (95% CI 0.08-0.51) and 0.20 (95% CI 0.08-0.54), respectively. Risk reductions were significant regardless of correction for rheumatoid factor positivity and presence of joint erosions. Risk of cardiovascular disease was significantly decreased in patients in the methotrexate plus sulfasalazine group and the methotrexate, sulfasalazine and hydroxychloroquine combination group, after correcting for hypertension, diabetes and hypercholesterolemia. Risk of cardiovascular disease was increased in patients who tested positive for rheumatoid factor and who had joint erosions, with odds ratios of 2.04 (95% CI 1.02-4.07) and 2.36 (95% CI 0.92-6.08), respectively. A significantly lower risk of cardiovascular disease was associated with patients who received methotrexate compared with patients who had never used any of the study DMARDs. CONCLUSION: The authors conclude that treatment with methotrexate could reduce the development of atherosclerosis, resulting in decreased risk of cardiovascular disease in patients with RA.