Acute coronary syndromes (ACS) are among the higher cardiovascular risks associated with Rheumatoid arthritis (RA).

We don't yet know how much DMARD-induced remission might lower the risk of ACS in RA compared to rates in the general population or whether DMARDs specifically have a protective effect on ACS risk.

Delcoigne and colleagues present new information on the risk of ACS in RA patients who achieved remission with methotrexate (MTX) or a tumour necrosis factor inhibitor (TNFi) in a session titled, From hearts to lungs: comorbidities in RA.

The researchers defined and pooled cohorts of RA patients from registers in Norway and Sweden. This included 14,488 treatment courses with MTX and 13,056 with TNFi.

Everyone had started MTX or a TNFi between 2012 and 2021 and was followed for 1 year from the first date at which remission was recorded until any ACS, death, emigration, treatment discontinuation, a new DMARD start, first non-remission date, or end of the study.

DAS28 remission was achieved in 40% and 32% of MTX- and TNFi-treated patients. During the 1-year follow-up, there were 15 and 12 ACS events in the MTX and TNFi cohorts, respectively - corresponding to crude incidence rates of 3.4 and 3.8 per 1000 person-years.

Comparing these incidence rates gave a hazard ratio (HR) of 1.19 for TNFi versus MTX. Other remission metrics provided similar and statistically non-significant estimates. The comparison of treated (MTX or TNFi) patients in remission to the general population provided an HR of 1.08, adjusted for age, sex and calendar year.

"Patients with RA who reach remission on MTX have a similar ACS risk as those reaching remission on TNFi," said Benedicte Delcoigne from the Karolinska Institutet in Stockholm, Sweden. "The incidence rates of ACS in patients in remission were comparable to the incidence rate in the general population."

A second abstract from Buch and colleagues looked at the impact of cardiovascular comorbidities on the efficacy of tofacitinib versus TNFi in RA. This was based on the observation that RA patients with a history of atherosclerotic cardiovascular disease (HxASCVD) have a higher risk of major adverse CV events (MACE) with tofacitinib versus TNFi, whereas risk difference is not detected in people with no HxASCVD. 

The researchers used data from ORAL Surveillance - an open-label, post-authorisation safety study that included patients with active RA despite MTX. Everyone was aged 50 or older and had at least one additional CV risk factor. In this post hoc analysis, patients were categorised by HxASCVD.

For those with no HxASCVD, the 10-year risk of ASCVD was determined using pooled cohort equations with a multiplier applied per EULAR guidelines.