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Autoimmune Diseases and Cardiovascular Risk
Quick Takes
- This is a population-based study in the UK examining the association between autoimmune disease and incident cardiovascular disease.
- All 19 examined autoimmune diseases were associated with a 1.5-3.5x increased risk of a broad swath of cardiovascular diseases—an association that was strongest in younger individuals and that was not attenuated by adjustment for cardiovascular risk factors.
- Cardiovascular risk prevention should be considered as an integral part of the management of autoimmune diseases.
Study Questions:
Are autoimmune diseases associated with an increased risk of cardiovascular disease?
Methods:
This is a population-based study using electronic health records from various data sets in the United Kingdom (UK) to identify individuals who were seen in general practice between 2000 and 2018, with at least 1 of 19 autoimmune diseases, and who were free of cardiovascular disease for 12 months after diagnosis of the autoimmune condition. The autoimmune group was compared to individuals matched 5:1 using age, sex, socioeconomic status, and region, who were free of autoimmune disease at any time. Both groups were followed up until June 30, 2019. The primary endpoint for the analysis was a composite of 12 fatal and nonfatal cardiovascular conditions, which were also examined individually.
Results:
Of 22,009,375 individuals in the UK electronic health record databases, 446,449 eligible individuals with autoimmune diseases (mean age 46.2 years, 60.8% women) were matched to 2,102,830 controls. During a median of 6.2 years (interquartile range, 2.7–10.8) of follow-up, 68,413 (15.3%) people with and 231,410 (11.0%) without autoimmune diseases developed incident cardiovascular disease. The incidence rate of cardiovascular disease was 23.3 events per 1,000 patient-years among patients with autoimmune disease and 15.0 events per 1,000 patient-years among those without an autoimmune disease (hazard ratio [HR], 1.56 [95% CI, 1.52–1.59]). An increased risk of cardiovascular disease with autoimmune disease was seen for every individual with cardiovascular disease and increased progressively with the number of autoimmune diseases present. The risks were highest for myocarditis, pericarditis, peripheral arterial disease, and infective endocarditis. Among autoimmune diseases, systemic sclerosis (3.59 [2.81–4.59]), Addison’s disease (2.83 [1.96–4.09]), systemic lupus erythematosus (2.82 [2.38–3.33]), and type 1 diabetes (2.36 [2.21–2.52]) had the highest overall cardiovascular risk. People with autoimmune disease had a twofold increase in the risk of developing cardiovascular disease before the age of 65 years compared to controls. Adjusting for cardiovascular risk factors minimally attenuated the increased risk associated with autoimmune diseases.
Conclusions:
The authors concluded that autoimmune diseases are associated with a significantly increased risk of fatal and nonfatal cardiovascular diseases.
Perspective:
Autoimmune diseases have long been associated with an increased risk of cardiovascular diseases. Despite this knowledge, there is a lack of awareness of that increased risk, and no guidelines considering patients with autoimmune diseases as a group of special interest for cardiovascular risk prevention. This well-conducted study brings this patient group in the forefront through providing population-based evidence supporting that association. The most notable finding is that all 19 autoimmune diseases examined conferred an increased cardiovascular risk that was not attenuated by adjustment for conventional risk factors, which points to dysregulated immune activation or inflammation as a factor central to the heightened risk—rather than a specific disease. The excess risk was highest in younger people, suggesting that the burden of inflammation accumulates with time. Targeting inflammation represents the next frontier in the prevention and treatment of cardiovascular diseases—a paradigm now supported by evidence of risk reduction using targeted immune modulators such as canakinumab. The authors say it best: ‘Cardiovascular risk prevention should be considered as an integral part of the management of autoimmune diseases.’
Clinical Topics: Heart Failure and Cardiomyopathies, Pericardial Disease, Prevention, Vascular Medicine, Atherosclerotic Disease (CAD/PAD)
Keywords: Autoimmune Diseases, Cardiovascular Diseases, Diabetes Mellitus, Type 1, Electronic Health Records, Endocarditis, Heart Disease Risk Factors, Inflammation, Lupus Erythematosus, Systemic, Myocarditis, Pericarditis, Peripheral Arterial Disease, Primary Prevention, Risk Factors, Risk Reduction Behavior, Scleroderma, Systemic, Vascular Diseases
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