As noted in the review by England et al, a multifaceted approach is needed to reduce the burden of cardiovascular disease (CVD), including optimal management of traditional risk factors as well as those intrinsic to rheumatoid arthritis (RA). It is clear that patients with RA have an increased risk of CVD. Although for a long time we did not have a clear explanation for this phenomenon, we now know that both RA and CVD are driven by systemic inflammation. Over the past 20 years, it has become clear that some of the same inflammatory mediators and cytokines involved in RA are also involved in the development of atherosclerosis. The inflammatory hypothesis (that CVD is driven by inflammation) is supported by several lines of evidence, including results from the Justification for the Use of Statins in Prevention: an Intervention Trial Evaluating Rosuvastatin (JUPITER) trial, which found that patients with elevated C-reactive protein levels were at an increased risk of CVD, even in the absence of hyperlipidemia. At the same time, it has recently been shown that blocking interleukin 1β reduces inflammation and is associated with a decreased cardiovascular (CV) risk (lower incidence of nonfatal myocardial infarction, nonfatal stroke, or cardiovascular death) that is independent of lipid level lowering. Thus, the presence of systemic inflammation in patients with RA is likely a significant part of the reason for the increased risk of CVD. Paradoxically, patients with RA and systemic inflammation may have decreased lipid levels, despite the increased CV risk in those with RA. Many treatments for RA that decrease systemic inflammation are associated with the elevation of lipids. This likely reflects the control of inflammation (and hence elevation of where the lipid levels would normally be), rather than an adverse effect of these drugs.

While the CV risk from traditional factors such as dyslipidemia and diabetes is well recognized, the CV risks associated with RA are likely underrecognized and undertreated. To lower CV risk, it is critical that disease activity in RA is controlled so that systemic inflammation is minimized. Additionally, the treatment of patients with RA should include aggressive management of CV risk factors such as smoking, overweight, and hyperlipidemia (eg, smoking cessation therapy is appropriate, and all patients who are candidates should receive lipid-lowering therapy with statins). Thus, patient education and related focused clinical efforts are important aspects of CV risk mitigation and aggressive disease control in RA.