Elevated Risk of Aortic Aneurysm in Rheumatoid Arthritis

Rheumatoid arthritis is associated with an elevated risk of aortic aneurysm, according to new research using data from Israel's largest health management organization.

The study is the first to show a link between rheumatoid arthritis and aortic aneurysm in a large population, despite the well-known risk for other cardiovascular comorbidities with the disease. One 1989 study found aortitis in 10 out of 188 patients with rheumatoid arthritis in autopsy; three of those showed aneurysmal dilation of the thoracic and abdominal aorta. A few individual case reports bolstered the argument for a connection, as did a 2014 study using data from an aortic aneurysm database in the United Kingdom. That research found a prevalence of 0.8 percent of aortic aneurysm in rheumatoid arthritis. No one had studied the question in a large sample or population cohort, however.

Howard Amital, M.D., of the Zabludowicz Center for Autoimmune Diseases at Sheba Medical Center in Tel-Aviv, and colleagues, had the chance to do just that. They used the database of Clalit Health Services, which covers about 4.4 million people, using a retrospective case-control design. Patients with a diagnosis of rheumatoid arthritis were identified and matched by age and sex with controls; diagnoses of aortic aneurysm was gleaned from primary care and hospital reports.

"This is not data that originates from a clinical study in which you're very selective with inclusion and exclusion criteria," Dr. Amital said in an interview with Rheumatology Network. "In other words, the data we have reflects, in a more precise manner, what really happens in real life."

The researchers identified 11,782 rheumatoid arthritis patients and 57,973 controls. In the rheumatoid arthritis population, 0.72 percent had a diagnosis of aortic aneurysm, significantly higher than the 0.49 percent proportion seen in the control group, Dr. Amital and his colleagues reported Aug. 9 in the journal Clinical Rheumatology. (Odds ratio 1.48, 95 percent confidence interval; 1.15-1.88, p=0.002.)

After controlling for demographics and smoking, the researchers found that aortic aneurysm remained significantly elevated in women with rheumatoid arthritis compared with healthy controls at a rate of 0.51 to 0.31 percent (O.R. 1.64, 95 percent C.I., 1.16-2.27, p=0.0006). Compared with their healthy counterparts, 60- to 79-year-olds with rheumatoid arthritis were likewise at elevated risk (0.98 percent versus 0.64 percent with an odds ratio of 1.55. 95 percent C.I.; 1.13-2.10, p=0.007.)

Smoking was a risk factor for aortic aneurysm in the rheumatoid arthritis patients, the researchers found, but the association remained even after smoking status was controlled for.

"RA is an additional risk factor and it has its own contribution to the generation of aortic aneurysms," Dr. Amital said.

It wasn't surprising to find the aortic aneurysm risk in these patients, he said, given the well-known etiology of atherosclerosis in rheumatoid arthritis. What's less clear is whether treating the rheumatoid arthritis will prevent the atherosclerosis, and thus the aortic aneurysm, he said.

"I can't say that we don't have studies," he said, "but it is less well-established."

Aortic aneurysms were the primary cause of death for more than 9,800 people in 2014, according to the Centers for Disease Control and Prevention, and about two-thirds of people with the condition are male. As such, the U.S. Preventative Services Task Force recommends ultrasound screenings for men ages 65 to 75.

Aortic aneurysm has previously been established as a risk for systemic lupus erythematosus patients, as well as those with giant cell arteritis and Takayasu's arteritis. The pathophysiology leading to aortic aneurysm in rheumatoid arthritis is unclear, Dr. Amital and his colleagues wrote, but atherosclerosis and vasculitis probably play a role. The disease has been linked to aortic stiffness, another potential contributing factor.

References:

Shovman O, Tiosano S, Comaneshter D, Cohen AD, Amital H, Sherf M. “Aortic aneurysm associated with rheumatoid arthritis: a population-based cross-sectional study.” Clin Rheumatol Clinical Rheumatology. September 2016. DOI:10.1007/s10067-016-3372-0. 

Gravallese EM, Corson JM, Coblyn JS, Pinkus GS, Weinblatt ME. “Rheumatoid aortitis: a rarely recognized but clinically significant entity.” Medicine. 1989;68(2):95-106. DOI: 10.1097/00005792-198903000-00003.

Panchal RR (2014) “An established entity in rheumatoid arthritis?” Rheumatology 53(suppl 1):i102 


Fleming C, Whitlock E, Beil T, Lederle F. “Screening for Abdominal Aortic Aneurysm: A Best-Evidence Systematic Review for the U.S. Preventive Services Task Force.” ACC Current Journal Review. 2005;14(6):15. DOI:10.1016/j.accreview.2005.05.037.

Sliem H, Nasr G. “Change of the aortic elasticity in rheumatoid arthritis: relationship to associated cardiovascular risk factors.” Journal of Cardiovascular Disease Research. 1(3):110–115. DOI: 10.4103/0975-3583.70901