RESEARCH ARTICLE

The Recognition and Assessment of Cardiovascular Riskin People with Rheumatoid Arthritis in Primary Care:A Questionnaire-Based Study of General Practitioners_ 69..74

Carolyn Bell MBBS, MRCP & Ian F. Rowe MD, FRCP

Worcestershire Royal Hospital, Worcester, UK

Abstract

Objectives. To investigate how well recognized the association between rheumatoid arthritis (RA) and excess

cardiovascular (CV) risk is within primary care and the current assessment strategies being employed by general

practitioners (GPs).

Methods. Questionnaires were sent to all 376 GPs in the Worcestershire Primary Care Trust.

Results. Thirty-two per cent of GPs identified RA as an independent risk factor for CV disease. Fifteen per cent and

34%, respectively, assessed their RA patients for primary and secondary prevention of their CV risks. Of those GPs

who made an assessment, 18.4% adjusted the calculated risk derived from standard charts. The frequency of

assessment was greater among GPs who had received a form of education about the association between CV disease

and RA. However, of the GPs identifying this susceptibility, only 40% performed any form of primary prevention risk

assessment.

Conclusions. At present, the excess risk of CV disease conferred by RA is under-recognized and under-assessed in

primary care. Currently, educational resources on this topic targeted at GPs are lacking and may in part account for

our findings. However, even when GPs did identify the risk of CV disease in RA or had received education about it,

this did not consistently change their clinical management. Further work to promote knowledge and management

strategies for CV disease in RA is therefore needed to improve the care of patients with this condition. Copyright ©

2010 John Wiley & Sons, Ltd.

Keywords

Rheumatoid arthritis; cardiovascular disease; risk assessment; primary care

Correspondence

Dr Carolyn Bell, Department of Rheumatology, Worcestershire Royal Hospital, Charles Hastings Way, Worcester WR5 1DD, UK.

Email: rheumatology@fastmail.co.uk

Published online 25 November 2010 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/msc.196

Introduction

Rheumatoid arthritis (RA) is a chronic inflammatory

disease affecting approximately 1% of the adult popu-

lation. Patients with RA are recognized as having a

shorter life expectancy by five to 10 years (Kvien, 2004)

and a standardized mortality rate (SMR) of 1.28–3.0

(Hall et al., 2005). Much of this excess mortality is

attributable to cardiovascular disease (CVD) (Wolfe

et al., 1994) and research to further our understanding

of the pathogenesis and evaluation of CV risk factors in

RA is ongoing.

In the UK, the majority of CV risk assessment and

management takes place within primary care and a

variety of risk calculators exist to guide management.

Currently, it is not clear to what extent general practi-

tioners (GPs) are aware of the relationship between RA

and CVD and if the presence of RA influences their

Musculoskelet. Care 9 (2011) 69–74 © 2010 John Wiley & Sons, Ltd. 69

choice of assessment method. It is essential that all

physicians involved in the care of RA patients are

aware of this association, particularly as the relative risk

of CV death in RA may be greatest in young patients

with no personal history of CVD (Solomon et al.,

2006), a population not traditionally identified as at

risk.

This study aimed to determine the extent to which

RA is identified as a risk factor for CVD in primary care

and the current assessment strategies being employed

by GPs to assess CV risk in these patients, with a view to

developing management protocols for any unmet needs

of primary care colleagues. CV disease in RA is well

represented in rheumatology journals and meetings;

however, a review of the literature found very few

articles aimed at primary care physicians.

Study population and methods

Questionnaires were posted to all 376 GPs identified as

currently practising by the Worcestershire Primary Care

Trust (PCT). Questionnaires were anonymous, to mini-

mize reporting bias, but requested the GP’s position

(e.g. partner/salaried GP) and whether they had a spe-

cialist interest in rheumatology. The questions are

shown in Figure 1 and included a prompt for Yes or No

answers.

Statistical analysis and ethical approval

Results are expressed as percentages, with absolutenumbers in brackets (n). Statistical analysis to comparegroups was calculated using online Graphpad software

1. In your daily practice, would you identify rheumatoid arthritis (RA) as an independent risk factor for cardiovascular disease?

2. Do you specifically target patients with RA for primary prevention of their cardiovascular risk factors?

2b. If yes, do you i) make the assessment during a consultation for another matter ii) invite the patient for an assessment iii) expect this to be undertaken in secondary care

3a. Do you specifically target patients with RA for secondary prevention of their cardiovascular risk factors?

3b. If yes, do you i) make the assessment during a consultation for another matter ii) invite the patient for an assessment iii) expect this to be undertaken in secondary care

4. Do you routinely multiply the calculated 10-year risk (derived from risk assessment charts) by 1.5 for patients with RA?

5. Do you routinely adjust the calculated 10-year risk (derived from risk assessment charts) in any other way for patients with RA (e.g. use diabetic chart)? If yes, please specify.

6. Has correspondence from your local rheumatology consultant communicated the increased risk of cardiovascular events?

7. Have you recently seen an article in a journal about RA and cardiovascular risk? If yes, which journal?

8. Have you recently attended a presentation about RA and cardiovascular risk? If yes, where?

9. Would you find a review article about RA and cardiovascular risk in primary care useful to your own practice?

10. Would you find a presentation about cardiovascular risk and RA in primary care useful to your own practice?

Figure 1 Questionnaire

Recognition and Assessment of CV Risk in RA Patients in Primary Care Bell and Rowe

70 Musculoskelet. Care 9 (2011) 69–74 © 2010 John Wiley & Sons, Ltd.

Fisher’s exact test, with a p value of �0.05 consideredas significant. Ethical approval was gained from theWest Midlands Research Ethics Committee.

Results

Questionnaires were returned by 55% (n = 207) of GPs.

Of these, 83% (n = 172) were partners, 15.5% (n = 32)

salaried GPs and 1.5% (n = 3) locums/other; 4.3% (n =9) declared a specialist interest in rheumatology. Table 1

outlines the key findings.

The majority of assessments (78%) were conducted

in a consultation made for any other matter, RA or

non-RA related, rather than specifically targeting

patients for CV risk management. 5.3% (n = 11) of GPs

indicated that these assessments should occur in sec-

ondary care as part of RA routine management.

GPs who identified the excess CV risk in RA or had

received education about RA were significantly more

likely to perform a primary CV risk assessment (p <0.0001) and adjust this risk for RA (p < 0.0001) than

those who had not. However, not all ‘identifying’

and/or ‘educated’ GPs actually effected a change in

their management (see Table 2). When questioned,

84% felt that a review article and 85% a presentation

about RA and CV risk in primary care would be useful

to their practice.

Discussion

Patients with RA are recognized to have excess morbid-

ity and mortality from CV disease and thus routine

primary and secondary assessment and management of

CV risk factors is essential (Luqmani et al., 2006).

The identification and assessment ofCV risk

This study revealed that less than a third (32%) of GPsidentified RA as a risk factor for CVD in their routinedaily practice. Even fewer (15%) performed routineprimary risk assessments for these patients or adjustedthe calculated risk (derived from standard charts) toaccount for the presence of RA. Assessment rates werebetter for secondary than primary prevention of CVrisk factors. National guidance already exists for thesecondary care of CVD for the whole population(Cooper et al., 2007) and so, theoretically, 100% ofRA patients should receive secondary risk assessmentfollowing a CV event, rather than the 34% reported inthis study.

Did identification alter managementpractices?

Our results suggest that even when GPs did identify RAas a risk for CVD, this did not always translate into theirmanagement practices. Of those ‘identifying’ GPs, only40% stated that they routinely targeted RA patients forprimary prevention. Several possible reasons for thisfinding exist. The free-text answers provided suggesteda lack of belief in the significance of the associationamong some GPs. There is also a current lack of trial

Table 1. The identification and assessment of CV risk in RA

% (n)

The proportion of GPs identifying RA as a risk factor

for CVD

32% (67)

The proportion of GPs targeting RA patients for

primary prevention of CVD

15% (31)a

The proportion of GPs targeting RA patients for

secondary prevention of CVD

34% (71)b

The proportion of GPs multiplying the calculated risk

by 1.5

12.6% (26)

The proportion of GPs adjusting the calculated risk in

another way

5.8% (12)c

a Eleven per cent (23) targeted for both primary and secondary

prevention.b This number is greater than the 32% identifying RA as a risk factor, as

four GPs who did not identify this risk stated that they targeted RA

patients for secondary prevention of CVD.c Six used Q risk2, which includes a multiplier for RA, one used a lower

threshold (than Joint British Societies [JBS] II guidance) of 15% to

commence treatment and the other five stated factors such as gender,

socioeconomic status and ethnicity.

Table 2. Did ‘identification’ or education about the excess riskof CVD in RA effect a change in management?

Total The proportion of the total

who then assessed primary

prevention of CV risk (n)

Identify RA as CV risk

factor

32% (67) 40% (27/67)

Had read article 20% (41)a 39% (16/41)

Had attended presentation 4% (8)a 50% (4/8)

Received consultant

communication

15% (31)a 32% (10/31)

a The sum of the three columns is greater than the total number of

‘identifying GPs’, as some GPs had received more than one form of

education.

Bell and Rowe Recognition and Assessment of CV Risk in RA Patients in Primary Care

Musculoskelet. Care 9 (2011) 69–74 © 2010 John Wiley & Sons, Ltd. 71

data to inform choice of treatments. The outcome andpublication of trials such as TRial of Atorvavstatin inthe primary prevention of Cardiovascular Endpoints inRheumatoid Arthritis (TRACE RA 2010) may go someway toward rectifying this situation, but the evidencefor other drugs, such as antiplatelet and antihyperten-sive agents, for primary prevention is lacking.

Another reason for the apparent disparity between‘identification’ and clinical practice may be the varietyof risk calculators available without clear recommenda-tions as to which best reflects RA patients’ vulnerabili-ties and conflicting advice on how to adjust theresulting score between publications from ArthritisResearch UK (AR-UK) (Symmons et al., 2006) and theEuropean League Against Rheumatism (EULAR)(Peters et al., 2010).

The prevalence of RA patients found to be at highrisk from commonly used CV risk algorithms(Framingham Risk Score [FRS], the National Choles-terol Education Program [NCEP], Systematic CoronaryRisk Evaluation [SCORE] and Reynolds Risk Score[RRS]) is subject to significant variation (Toms et al.,2010). In addition, the National Institute for Health andClinical Excellence (NICE) recently retracted its rec-ommendation to use FRS for estimating CV risk in thegeneral population. While the FRS may underestimateCV risk in young women and inflammatory conditions(Chung et al., 2006), the absence of an alternative rec-ommendation may add to GPs’ uncertainties whenassessing their RA patients’ risk. A review of the litera-ture suggests that this problem may extend beyond theUK; for example, in the USA the American Heart Asso-ciation guidance (Pearson et al., 2002) also does notspecify which risk calculator to use.

We found that six of the GPs accounting for RA intheir CV risk estimation did so using Q Risk2. This is avalidated algorithm for estimating CVD, incorporatingindividual risk factors to improve the accuracy of thederived risk. It includes a multiplier for RA, with anadjusted hazards ratio of 1.5 for women and 1.38 formen (Hippisley-Cox et al., 2008). This is applied to allpatients with RA, in contrast to EULAR guidance,which requires two out of three of the factors diseaseduration >10 years, rheumatoid factor or anti-cycliccitrullinated peptide (CCP) antibody positivity or thepresence of extra-articular manifestations (Peters et al.,2010). However, in primary care, this information maynot be readily available; thus, Q Risk2 represents analgorithm incorporating traditional risk factors plus the

excess risk bestowed by RA, which may be acceptableand familiar to GPs.

The Quality and Outcomes Framework (QOF) is asystem for the performance management and paymentof GPs in the National Health Service (NHS). Atpresent, musculoskeletal conditions, and, as such, RAand management of its excess CV risk, is not included(NHS Information Centre, 2008/09). This omissionmay have profoundly affected the resources and timeavailable for GPs to perform these reviews. This issupported by the finding that, where risk assessmentswere performed, the majority were during a consulta-tion with the patient for another matter, rather thanspecifically targeting patients – a far from robustsystem. The addition of musculoskeletal conditions tothe QOF therefore requires serious consideration.

An unmet educational need

This study demonstrates that the majority of GPs didnot identify RA as a risk factor for CVD. Only rela-tively small numbers had received any form of educa-tion on this topic and the majority of GPs reported thata presentation or publication aimed at primary carewould be useful to their clinical practice. Articlesabout RA and CVD are in abundance in specialist jour-nals; the low proportion of GPs having seen sucharticles suggests that these forums are inaccessible toGPs and that publication in primary care journals isneeded.

Our study supports the concept that receiving educa-tion on this subject will increase the number of GPsperforming risk assessments in RA patients. GPs whohad received a form of education (read an article,attended a presentation or received advice from a con-sultant rheumatologist) were significantly more likelyto assess and adjust their RA patients’ CV risk thanthose who had not. We also found that GPs who hadattended a presentation were most likely to modify theirpractice, although this should be interpreted with somecaution, as numbers in this group were small (n = 8) andcould represent GPs with a particular interest in CVrisk, despite only one declaring a specialist interest inrheumatology.

These findings therefore show evidence of an unmeteducational need among our primary care colleaguesand provide support for the correction of this in orderthat RA patients receive the routine care (Luqmaniet al., 2006, 2009) they warrant and to improve the

Recognition and Assessment of CV Risk in RA Patients in Primary Care Bell and Rowe

72 Musculoskelet. Care 9 (2011) 69–74 © 2010 John Wiley & Sons, Ltd.

under-treatment of RA patients with statins (Tomset al., 2010).

Where should CV risk managementtake place?

The issue of where and by whom the process of CV riskassessment of RA patients should be undertakenremains a source of discussion. Only 5% of GPs in thisstudy indicated that they felt this should be undertakenin secondary care, suggesting perceived ownership ofthis duty within primary care. GPs are likely to be mostexperienced in managing the traditional CV risk factorsfor RA patients; however, the excess risk in RA isknown to involve specific risk factors, such as inflam-mation and the effects of drugs (Radovits et al., 2009;Steen et al., 2009). The number of patients and fre-quency of consultations in secondary care do not lendthemselves to the sole performance of this task either.The model of shared care established in drug monitor-ing could be extrapolated to CV risk management, withexplicit but integrated roles for both primary and sec-ondary care physicians.

Conclusion

In conclusion, this study is the first to highlight the

sub-optimal awareness and assessment of the excess risk

of CV disease in RA within primary care, and the unmet

educational needs of GPs in a sample representative of

GPs in the NHS, albeit within the limitations of one

geographical region. Further emphasis needs to be

placed on communicating developments in the man-

agement of CV disease in RA into primary care and

clarifying existing guidance tailored to usual local prac-

tice. Rheumatologists need to engage with this process

in order to facilitate the optimal management of

patients with RA.

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