Check out A Patient’s Guide to Understanding Rheumatoid Arthritis and Heart Disease for more information on this topic.
Having rheumatoid arthritis (RA) means your risk of having a heart attack, stroke, or other serious cardiovascular issue is far higher than average. Research has shown that people with RA are nearly 50 percent more likely to develop cardiovascular disease and 50 percent more likely to die from it from it compared to the general population. Read more here about why RA patients face this increased heart disease risk.
While that’s clearly bad news, a rheumatoid arthritis diagnosis does not mean you’re doomed to have heart problems. You are not powerless. In fact, there are many steps you can take to protect your heart and blood vessels.
In honor of American Heart Month this February, here are 28 things you can do to lower your risk of heart disease if you have rheumatoid arthritis.
1. Don’t ghost your primary care doctor
While many rheumatologists are becoming more interested in the connection between RA and cardiovascular disease, matters of the heart and blood vessels are still primarily the domain of your primary care physician. In some cases, you may also need to see a cardiologist.
Patients often have such a hard time finding the right rheumatologist that once they do they don’t want to bother having to find other health care providers too, says rheumatologist Iris Navarro-Millan, MD, Assistant Professor of Medicine at Weill Cornell Medical College and Assistant Attending Physician at Hospital for Special Surgery in New York City. The problem is that even the most standard of heart health checks, like getting a cholesterol test, may fall through the cracks. See your primary care doctor at least once a year.
2. Have a heart-to-heart (pun intended) with your rheumatologist
“It’s important that rheumatologists bring up [heart health], but that doesn’t seem to be happening,” says Dr. Navarro-Millan. She wants patients to feel empowered to put their concerns on their rheumatologist’s radar. It can be as simple as telling your rheumatologist that you’ve recently read about the increased risk of heart disease in people with RA and want to know what it means for you personally.
If your doctor merely says you’re at high risk for cardiovascular disease, press them for more information about how it ought to be managed and monitored. You might be referred back to your primary care doctor or a cardiologist, but “I think this is a discussion patients and rheumatologists should be having,” says Dr. Navarro-Millan.
3. Talk to your rheumatologist about glucocorticoids (corticosteroids)
These drugs, which include prednisone, can have a number of different side effects, which is why experts recommend either avoiding them or using the lowest dose possible for the shortest amount of time possible. When it comes to heart disease risk, glucocorticoids can raise blood pressure, cholesterol, and blood sugar, says rheumatologist Christie Bartels, MD, Associate Professor at the University of Wisconsin in Madison.
If you’ve been taking glucocorticoids and decide with your rheumatologist to stop or lower the dose, remember that you’ll need to wean off slowly or risk serious side effects.
4. Take your disease-modifying antirheumatic drugs (DMARDs) as prescribed
One of the best things you can do for both your RA and your heart is to stick with your disease-modifying medication, like methotrexate, biologics, or JAK inhibitors. These treatments certainly help with rheumatic disease symptoms like joint pain, but there’s also some evidence that they reduce cardiovascular disease risk as well, says Dr. Bartels. That is likely because of their ability to dampen inflammation throughout the body.
5. Know that JAK inhibitors and IL-6 blockers might raise cholesterol
JAK inhibitors for RA include tofacitinib (Xeljanz), baricitinib (Olumiant), and upadacitinib (Rinvoq). Interleukin-6 inhibitors include tocilizumab (Actemra) and sarilumab (Kevzara). These drugs work well for some RA patients, so unless you already have high cholesterol there’s no need to dismiss them out of hand. That said, it’s smart to get your cholesterol checked before starting these drugs and again after you’ve been taking them for about six weeks, says Dr. Bartels.
6. Know your heart health numbers
These include your cholesterol, blood pressure, and blood sugar. Your body mass index (BMI) matters too. Keeping all of these in a healthy range helps lower your risk of cardiovascular disease. If any of these numbers are high, ask your doctor whether making specific lifestyle changes or taking certain medications might help.
- Blood pressure should ideally be less than 120/80 mm Hg
- LDL cholesterol should ideally be less than 100 mg/dL
- A1C (a measure of blood sugar) should ideally be less than 5.7%
- BMI should ideally be between 6-24.9.
7. Ask your doctor to calculate your personal risk of cardiovascular disease
Some health care providers use the American College of Cardiology (ACC)/American Heart Association (AHA) risk calculator. It takes into account risk factors (such as age, weight, cholesterol, and smoking and diabetes status) to predict your chances of having a heart attack or stroke in the next 10 years. Because RA is an additional risk factor, the European League Against Rheumatism (EULAR) advises multiplying this risk score by 1.5. How useful this multiplier is unclear, however, so it’s okay if your doctor decides to skip it. However, they should keep in mind that someone on the threshold of being high risk probably ought to be bumped up as a result of having RA, says Dr. Bartels.
Some physicians might also suggest ordering a Vectra test, which was originally designed to calculate RA disease activity but has since been recalibrated so it can also provide a cardiovascular risk score. The test uses blood biomarkers as well as risk factors like age, smoking, and diabetes.
8. Stay focused on rheumatoid arthritis low disease activity or remission
Traditional cardiovascular disease risk factors matter a lot, but so does keeping your rheumatoid arthritis in check. “There is very good data showing that when you control RA disease activity, your cardiovascular disease risk goes down,” says George A. Karpouzas, MD, Professor of Medicine at the David Geffen School of Medicine at UCLA and Chief of Rheumatology at Harbor-UCLA Medical Center in Los Angeles. “It’s not achievable for all patients, and it’s not a steady state — long-lasting remission is rare, but it’s something we should be striving for,” which likely means making adjustments to your medication regimen. “Our mission is remission.”
9. If you smoke, quit
Smoking raises the likelihood that your RA will be more severe and harder to get into remission, plus it’s terrible for your heart (not to mention your lungs, which are also vulnerable to RA-related inflammation and damage). The chemicals in cigarette smoke damage your heart and blood vessels, increase blood pressure, and promote the buildup of plaque in your arteries. Quitting smoking isn’t easy, so don’t go it alone. Talk to your doctor or visit smokefree.gov to make a plan, get the support you need, and increase your odds of success.
10. If your doctor prescribes a statin for your cholesterol, take it
Cholesterol-lowering medication isn’t right for everyone, but if your doctor deems it appropriate for you, make sure that you stick with it. More research is needed, but there is evidence that these medications might be even more effective in reducing cardiovascular events (like heart attack and stroke) among people with RA than they are in the general population, says Dr. Navarro-Millan. Research has found that people with RA with elevated LDL cholesterol who were put on a statin reduced their risk of having a cardiovascular event by 29 to 50 percent.
11. If your doctor prescribes medication for diabetes or prediabetes, take it
Chronically elevated blood sugar damages blood vessels, which is why people with diabetes are twice as likely as others to have a heart attack or stroke. Add that to the increased heart disease risk you face as someone with RA and you could really be in trouble. Keeping both your blood sugar and your RA disease activity well-controlled helps protect your heart.
12. Get physical activity every day
Exercising when you have joint pain might seem like a bad idea, but in fact the opposite is true. “Physical activity is good for your RA and your cardiovascular health,” says Dr. Bartels. Walking is a great low-impact option, as is water aerobics, swimming, and using an elliptical trainer. You can start small, aiming for just 10 or 15 minutes of physical activity a day, working your way up to 30 minutes a day.
13. Know your family history of heart disease
You can’t change your genes, but if you have inherited a predisposition to cardiovascular disease your doctor should know about it because it impacts your personal heart disease risk. It’s especially critical to tell your doctor if a first-degree relative (parent or sibling) had a heart attack, stroke, or other serious cardiovascular event at a young age (under age 65 for women and age 55 for men). Your doctor might want to run additional tests or start you on preventive medications sooner than if you did not have a family history of heart trouble.
14. Eat more whole grains instead of refined grains
While fiber may be best known for keeping your digestive system working smoothly, it’s also crucial for a healthy heart. Research has shown that people who don’t get enough fiber are more apt to have high blood pressure, high LDL cholesterol, and too much dangerous belly fat, all of which raises the odds of having a stroke or heart attack. Try swapping the white stuff for whole wheat pasta, brown rice, and whole grain bread.
15. Eat plenty of colorful veggies
Vegetables are also great sources of fiber, plus they’re packed with antioxidants. Antioxidants are powerful substances that counteract free radicals in the body, which lowers inflammation throughout your body, including in your joints and blood vessels. Antioxidants also lower the risk of cardiac events like heart attacks and strokes, possibly by interfering with changes to the plaque in your arteries so it doesn’t become as dangerous. The easiest way to make sure you’re getting enough: Fill half your dinner plate with produce. Leave a quarter for lean protein and a quarter for healthy carbs.
16. Go fish
Eating more fatty fish might help ease your joint pain and perhaps lessen RA disease activity thanks to omega-3s — heart-healthy fatty acids that combat inflammation. Some research has also shown that fish oil might reduce the risk of cardiovascular events in people with RA. Aim for at least 2 servings of omega 3-rich fish like salmon or mackerel each week.
17. Lose weight if you’re overweight
Excess fat cells may contribute to inflammation, further worsening your RA as well as increasing your chances of developing heart disease. Losing weight and keeping it off isn’t easy, but shedding just five to 10 percent of your body weight can help a lot. Your blood pressure, cholesterol, and blood sugar levels should improve, as will your risk of having a heart attack or stroke.
18. Scale back on salt
Most Americans consume way too much sodium, which pulls water into your blood vessels and raises blood pressure. In addition to going easy with the salt shaker, watch out for hidden sources of sodium in packaged food. Canned soups, bottled salad dressings, and frozen dinners are often loaded with it, so limit packaged foods and read labels carefully. Look for low-sodium options and aim to consume less than 2,300 milligrams of sodium a day.
19. Ditch the pop
Research has found that women who drink a lot of regular soda are more likely to develop RA. Although the reason isn’t clear, soda’s high sugar content may increase inflammation and even increase the risk of infections like gum disease that have been linked to RA. Meanwhile, other studies have found that people who drink two or more sugar-sweetened drinks per day are one-third more likely than those who rarely sip the sweet stuff to have a fatal heart attack or stroke. Replace soda with flavored seltzer or sparkling water.
20. Stay social
The COVID-19 pandemic has made it especially difficult to connect with others, which can make you feel isolated and lonely. But a lack of strong social ties has implications for your heart health: In fact, research has suggested that loneliness might be as bad as smoking as far as your risk for heart disease is concerned. Try to find some creative ways to maintain valued connections, whether it’s scheduling a Zoom date with an old friend or taking a masked walk outdoors with a neighbor.
21. Get a grip on stress
When you’re feeling frazzled your body pumps out the stress hormone cortisol, which may cause your immune system to act up and raise the risk of an RA flare. That same fight-or-flight hormone, if chronically elevated, can lead to high blood pressure, blood sugar, and cholesterol, as well as promote the buildup of plaque in your arteries. Stress is often unavoidable, but you can cope with it better by practicing meditation, deep breathing techniques, or just giving yourself time to unwind and focus on hobbies like crafting or reading.
22. Make sleep a priority
Skimping on sleep has been linked to an increased risk of cardiovascular problems, according to preliminary research presented at a 2020 American Heart Association conference: The study found that people who got less than 6 hours of shut-eye per night were more apt to have type 2 diabetes, high blood pressure, and score more poorly on overall measures of cardiovascular health compared to those who were better rested. Unfortunately, many RA patients have trouble sleeping, in part because they’re in pain. If you struggle with getting adequate, good-quality rest, talk to your rheumatologist and/or a sleep specialist.
23. Don’t ignore depression
Depression and chronic physical health problems often go hand in hand, and RA is no exception. In addition to making you feel mentally lousy, depression takes a physical toll, including on your heart. Evidence suggests that adults who have clinical depression have a 64 percent greater risk than non-depressed folks of developing coronary artery disease. If you have symptoms of depression (including feeling unusually sad, irritable, or hopeless) that have persisted for more than two weeks, talk to your doctor or a mental health professional.
24. Laugh it off
Watch a funny movie or find ways to chuckle at the absurdity of modern-day life. Whatever makes you giggle, go with it. Laughter prompts your body to produce feel-good endorphins that lower your blood pressure. Enthusiastic laughter also leads your blood vessels to dilate and release nitric oxide, which combats inflammation and plaque formation.
25. Brush and floss thoroughly
A healthy smile has benefits for the rest of your body. Emerging research suggests that the same bacteria that cause gum disease may trigger RA. Bacteria in your mouth can get into your bloodstream, and travel through your body, and lead to inflammation anywhere (including your joints). Gum disease is also strongly associated with having a serious cardiac event like a heart attack or stroke. In addition to brushing and flossing daily, make sure you see your dentist at least twice a year.
26. Measure your middle
Even if you’re not overweight per your body mass index (BMI), carrying too much visceral belly fat—the kind that sits deep within the abdomen and wraps around the organs in that area—is particularly bad for your heart and vessels. Grab a tape measure. A waist circumference of less than 35 inches for a woman or less than 40 inches for a man is considered healthiest for your heart. If yours is too wide, getting more aerobic activity and cutting back on carbs(especially refined ones) should help melt excess fat from wherever you’re storing it (including your middle).
27. Know heart attack warning signs
Everyone should know what might signal a heart attack, but it’s especially key if you’re at elevated risk because of RA or other risk factors. Crushing chest pain that spreads to your arm is common, but symptoms can vary. Some people suddenly feel nauseated, short of breath, or sweaty for no apparent reason. Back, stomach, and jaw pain are also possible symptoms. If you suspect you might be having a heart attack, call 911 immediately.
28. Act FAST for signs of stroke
FAST stands for Facial drooping, Arm weakness, Speech difficulty, and Time to call 911. As with a heart attack, a stroke requires quick medical attention. The faster you get help, the more likely you are to survive and avoid serious disability.
This article is part of A Patient’s Guide to Understanding Rheumatoid Arthritis and Heart Disease and was made possible with a grant from Myriad Genetics, Inc.
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Interview with George A. Karpouzas, MD, Professor of Medicine at the David Geffen School of Medicine at UCLA and Chief of Rheumatology at Harbor UCLA Medical Center in Los Angeles
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