If you have rheumatoid arthritis and are thinking about having joint surgery, you hear conflicting messages about the risk to your heart.
A 2016 Australian study published in the journal Arthritis Research & Therapy suggests that individuals with RA may be at increased risk of having a heart attack after joint surgery compared with their counterparts who do not have the disease. The study found that RA patients had significantly more heart attacks — myocardial infarctions — six weeks and one year after joint surgery, especially when the surgery involved the knees and shoulders, followed by the wrist and hands.
These results are not definitive, though. The study researchers did not see the same increased risk when they looked at only the results for total knee and hip replacements. They also reported that their results mirror the conclusions of some studies, but are at odds with others that have not found any increased risk of heart attack after joint surgery, but they acknowledge that few studies have specifically examined the incidence of heart attack in individuals with RA who have joint surgery.
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Dr. Susan Goodman, a rheumatologist at the Hospital for Special Surgery in New York, agrees that there is an overall lack of research in this arena. “Postoperative cardiac risk has never been studied and linked to RA disease activity,” she says.
“Patients with RA have a significantly increased risk of cardiac disease” when compared with similarly age- and gender-matched individuals who do not have RA, Goodman says. “Cardiac risk for patients with RA is greatest when the RA is poorly controlled, there is active inflammation and functional capacity is poor,” she explains. Modern drug therapy with disease-modifying anti-rheumatic drugs and biologic medications “decrease inflammation, and cardiac risk can normalize when RA inflammation is well-controlled,” she adds.
Goodman, who is also an assistant professor of medicine at Weill Cornell Medical College in New York, also compares the risk of heart attack in people with RA and those who have diabetes, another disorder that carries an increased risk of heart disease, with the general public.
“The risk of myocardial infarction overall is similar for patients with diabetes or RA,” Goodman says, but “patients with RA have a substantially lower rate of cardiac events and death after [joint surgery] than patients with diabetes [who have the same surgery].”
“It is not known why patients with RA do so much better after [joint surgery] than comparable at-risk patients, and it may relate to the heightened awareness of cardiac disease in patients with RA,” she says, noting that “in-hospital mortality after [joint replacement surgery] is no different for patients with RA compared to those without RA.”
“It [is] perhaps unsurprising that patients with RA appear to be at greater risk of having heart disease,” says Dr. Seth Leopold, a hip and knee surgeon in Seattle and a professor in the Department of Orthopaedics and Sports Medicine at the University of Washington School of Medicine. “RA is a chronic disease, [and] though it is more controllable now than it was in the past, many patients with RA have other medical conditions. It can be hard to separate all this out in studies,” he says.
“I certainly agree that patients with RA are much less likely to have complications after elective surgery than patients with diabetes, and that patients with well-managed RA do better than those with poorly managed RA,” adds Leopold, who is the editor in chief of Clinical Orthopaedics and Related Research , an international journal of orthopedic surgery. “All of this seems evident from the available research, and my own experience has been similar.”
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So do people with RA need to take special precautions before and after joint surgery to decrease the risk of having a heart attack? Because they are at a higher risk of having heart disease than people who do not have the disease, certain precautions are probably prudent.
“Most clinicians follow the guidelines of the American College of Cardiology/American Heart Association for preoperative cardiac risk assessment,” Goodman says. “These guidelines combine known cardiac risk factors with functional capacity.”
The American Heart Association defines functional capacity as the ability of an individual to perform the activities of daily living that require sustained aerobic metabolism, or activity. “Since many patients with RA are not able to exercise sufficiently to demonstrate their cardiac reserve, additional cardiac testing is frequently needed,” Goodman explains.
Also, according to Goodman, typical methods of determining cardiac risk use classic cardiac risk factors, such as known heart disease, a history of previous heart attack, congestive heart failure, hypertension, diabetes, kidney disease, smoking, advanced age, high cholesterol and other measures. These “may underestimate cardiac risk in patients with RA, who may have low cholesterol levels when the disease is active,” Goodman says. “Some rheumatologists take a pragmatic approach and add RA as a cardiac risk.”
Medication management may also be an important step in mitigating potential cardiac risk of joint surgery. “Cardiac risk for patients with RA is directly linked to disease activity; DMARDs and biologics decrease cardiac risk,” Goodman says. “However, this is a long-term risk reduction strategy. Standard perioperative management includes withholding biologics at the time of surgery.”
These include drugs that suppress the immune system and increase the risk of infection, like some of the biologics and corticosteroids.
“It seems to me that with the steps that Dr. Goodman recommends — which I would consider part of good care for anyone undergoing elective surgery — it should be possible to make surgery reasonably safe for most patients with RA,” Leopold says.
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So what is the bottom line for people with RA who are considering having joint surgery?
“It is tempting to speculate that cardiac risk is low after [joint replacement surgery] for patients with RA because most seek elective surgery when their disease is under good control,” Goodman says. However, it’s important to remember that “all [joint replacement] procedures carry a defined risk of complications, including cardiac events,” she notes, but overall, “patients with RA are not at an increased risk compared to non-RA patients in the surgical setting.”
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Do RA Patients Face Higher Risk of Heart Attacks After Joint Surgery? originally appeared on usnews.com
