(2016) Prevalence of ischemic heart disease and associated factors in patients with rheumatoid arthritis in Southern Brazil

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www.reumato logia .com.br
REVISTA BRASILEIRA DE
REUMATOLOGIA
Origina
Preva
assoc
arthri
Rafael K
Ana Isa
Mateus 
Cynthia
a Centro de E
b Fundac¸ão 
c Fundac¸ão 
d Universida
a r t i c 
Article histor
Received 31
Accepted 8 
Available on
Keywords:
Rheumatoid
Cardiovascu
Acute myoc
Prevalence
∗ Correspon
E-mail: g
http://dx.do
2255-5021/©
licenses/by-
 this article in press as: Gomes RK, et al. Prevalence of ischemic heart disease and associated factors in patients with rheumatoid
 Southern Brazil. Rev Bras Reumatol. 2017. http://dx.doi.org/10.1016/j.rbre.2017.01.006
l article
lence of ischemic heart disease and
iated factors in patients with rheumatoid
tis in Southern Brazil
miliauskis Santos Gomesa,∗, Ana Carolina Albersb,
dora Pianowski Salussogliab, Ana Maria Bazzanb, Luana Cristina Schreinerb,
Oliveira Vieirab, Patrícia Giovana da Silvab, Patrícia Helena Machadob,
 Mara da Silvab, Mauro Marcelo Mattosc, Moacyr Roberto Cuce Nobred
specialidades dos Municípios de Blumenau e Brusque, Blumenau, SC, Brazil
Regional de Blumenau, Faculdade de Medicina, Blumenau, SC, Brazil
Regional de Blumenau, Departamento de Sistemas e Computac¸ão, Blumenau, SC, Brazil
de de São Paulo, Instituto do Corac¸ão, Unidade de Epidemiologia Clínica, São Paulo, SP, Brazil
l e i n f o
y:
 March 2016
November 2016
line xxx
 arthritis
lar disease
ardial infarction
a b s t r a c t
Objective: To estimate the prevalence of ischemic heart disease and associated factors in
patients with rheumatoid arthritis.
Methods: A cross-sectional study using the American College of Rheumatology diagnostic
criteria in order to select patients seen at primary or secondary health care units in Blu-
menau, Santa Catarina, Southern Brazil, in 2014. The presence of ischemic heart disease
was defined as an acute myocardial infarction with percutaneous coronary intervention or
coronary artery bypass graft surgery that has occurred after diagnosis. Fischer’s exact test,
Wald’s linear trend test, and multivariate logistic regression analysis were used to test the
associations.
Results: Among 296 patients (83.1% female) with a mean age of 56.6 years and a mean
rheumatoid arthritis duration of 11.3 years, 13 reported having acute myocardial infarc-
tion requiring a percutaneous or surgical reperfusion procedure, a prevalence of 4.4% (95%
CI 2.0–6.7). Diabetes Mellitus (odds ratio [OR] 4.9 [95% CI 1.6–13.8]) and disease duration >10
years (OR 8.2 [95% CI 1.8–39.7]) were the only factors associated with an ischemic disease
that remained in the final model, after the multivariate analysis.
Conclusion: The prevalence of acute myocardial infarction was similar to that observed in
other studies. Among the traditional risk factors, Diabetes Mellitus, and among the fac-
tors related to rheumatoid arthritis, disease duration, were the variables associated with
comorbidity.
© 2017 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
ding author.
omesmed2002@ibest.com.br (R.K. Gomes).
i.org/10.1016/j.rbre.2017.01.006
 2017 Elsevier Editora Ltda. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
nc-nd/4.0/).
Please cite
arthritis in
ARTICLE IN PRESSRBRE-350; No. of Pages 7
2 r e v b r a s r e u m a t o l . 2 0 1 7;x x x(x x):xxx–xxx
Prevalência de doenc¸a isquêmica cardíaca e fatores associados em
pacientes com artrite reumatoide no Sul do Brasil
Palavras-cha
Artrite reum
Doenc¸a card
Infarto agud
Prevalência
da d
e.
usou
s aten
a Ca
om i
vasc
iac¸õe
ressã
83,1%
nos, 
 repe
ttus (
 (raz
 isqu
arto 
ores d
littus
ora L
C-ND
Introduct
Rheumatoi
mune dise
synovial m
and functio
0.24 to 1% 
women and
In Brazil, tw
a variation
country,5 a
Studies 
ease (CVD
population
important 
dial infarct
event.9,10 S
that the pr
The gre
patients is
tional risk f
of RA patie
occurrence
logic diagn
the disease
role in the 
lation of se
independen
disease.16,1
pite 
eatm
 to th
mato
ve:
atoide
iovascular
o do miocárdio
r e s u m o
Objetivo: Estimar a prevalência 
pacientes com artrite reumatoid
Métodos: Estudo transversal que 
tologia para selecionar paciente
secundária em Blumenau, Sant
cardíaca isquêmica foi definida c
ana percutânea ou cirurgia de re
diagnóstico. Para testar as assoc
linear de Wald e a análise de reg
Resultados: Entre 296 pacientes, 
de artrite reumatoide de 11,3 a
necessitou de procedimento de
(IC 95% 2,0-6,7). O diabetes meli
de doenc¸a maior do que 10 anos
fatores associados com a doenc¸a
multivariada.
Conclusão: A prevalência de inf
em outros estudos. Entre os fat
artrite reumatoide, o diabetes me
comorbidade.
© 2017 Elsevier Edit
BY-N
ion
d arthritis (RA) is a systemic inflammatory autoim-
Des
able tr
is due
inflam
 this article in press as: Gomes RK, et al. Prevalence of ischemic heart dise
 Southern Brazil. Rev Bras Reumatol. 2017. http://dx.doi.org/10.1016/j.rbre.2
ase characterized by the involvement of the
embrane of peripheral joints leading to destruction
nal limitation.1 The prevalence of RA varies from
of the adult population, with a predominance of
 a higher incidence in the 30–50-year age group.2–4
o studies were published. The first study shows
 from 0.2 to 1%, depending on the region of this
nd the other establishes a prevalence of 0.46%.6
point to an increased risk of cardiovascular dis-
) in patients with RA compared to the general
.7–9 CVD exerts a great impact and represents an
morbidity in patients with RA, and acute myocar-
ion (MI) is considered to be the most common
tudies conducted in different countries indicate
evalence can vary from 1 to 17%.10–12
atest number of cardiac ischemic events in RA
 not entirely explained by the presence of tradi-
actors alone.10 A study in Sweden with two cohorts
nts demonstrated that there is no increase in the
 of ischemic heart disease prior to the rheumato-
osis.13 On the other hand, soon after the onset of
14 and along its course,15 RA plays an important
onset of MI, above all in patients with an accumu-
verity markers.10 Thus, RA was considered as an
t risk factor for the occurrence of coronary artery
7
developme
for exampl
traditional 
to the pers
periods.7
The pre
prevalence
possible as
Santa Cata
Materials
This is a c
between Ju
aged 20 ye
to the Am
ria, residen
Brazil. In 2
ment index
municipali
also in the
the age gr
bitants, eq
municipali
oenc¸a isquêmica cardíaca e os fatores associados em
 o critério diagnóstico do Colégio Americano de Reuma-
didos nas unidades de saúde da atenc¸ão primária ou
tarina, sul do Brasil, em 2014. A presenc¸a de doenc¸a
nfarto agudo do miocárdio com intervenc¸ão coronari-
ularizac¸ão do miocárdio que tenha ocorrido depois do
s usou-se o teste exato de Fischer, o teste de tendência
o logística multivariada.
 de mulheres, com média de 56,6 anos, tempo médio
13 relatam ter tido infarto agudo do miocárdio que
rfusão percutânea ou cirúrgica, prevalência de 4,4%
razão de chance de 4,9 [IC 95% 1,6-13,8]) e o tempo
ão de chance de 8,2 [IC 95% 1,8-39,7]) foram os únicos
êmica que permaneceram no modelo final após análise
agudo do miocárdio foi semelhante com a observada
e risco tradicionais e entre os fatores relacionados à
 e o tempo de doenc¸a foram as variáveis associadas à
tda. Este e´ um artigoOpen Access sob uma licenc¸a CC
 (http://creativecommons.org/licenses/by-nc-nd/4.0/).
the important advances in diagnosis and avail-
ents, there remains a high CVD morbidity.10 This
e combination of the characteristics of a chronic
ry disease, which are predisposing factors to the
ase and associated factors in patients with rheumatoid
017.01.006
nt of comorbidities; of the drugs used in treatment,
e, glucocorticoids11; to an increased prevalence of
risk factors over the duration of disease18,19; and
istent activity of the disease in its most aggressive
sent study aimed to estimate the self-reported
 of coronary ischemic events and to identify the
sociated factors in patients with RA in Blumenau,
rina, Southern Brazil, in 2014.
 and methods
ross-sectional, population-based study conducted
ly 2014 and January 2015 with men and women
ars and older with rheumatoid arthritis according
erican College of Rheumatology (1987) crite-
ts in the municipality of Blumenau, Southern
010, Blumenau had a municipal human develop-
 (IDH-M) = 0.806, ranking 25th among all Brazilian
ties.20 According to the national census conducted
 year of 2010, the number of people pertaining to
oup of this study corresponded to 221,839 inha-
uivalent to 71.7% of the total population of the
ty.21
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336 
296
286
1110
Estimated population of patients
To calcu
prevalence
lowing par
(1110 patie
come = 50%
The sample
ple collecti
records in t
outpatient 
ing room at
city (Fig. 1).
Househo
meeting th
nighttime v
cases of ref
The tea
medical sch
menau (FU
interview a
phone in a
supervisor.
respondent
through the
The dep
tive history
of rheuma
infarction d
catheteriza
coronary ar
The ind
graphic var
in a group
more for the elderly; (b) traditional cardiovascular risk factors
d in the interview: previous diagnosis of hyperten-
iabe
ch d
t pr
 hist
e (m
rizat
weig
Hea
 ≤24
/m2)
and 
tivel
eum
 data
heir 
al fi
Colle
re an
rd de
nd f
les. T
ic ev
d, w
fter
ed,
h th
ed od
ls.
 the 
les w
aken
Calculated sample
Patients identified
Patients interviewed
Losses – total 40 patients
Death – 20
Refuse – 12
Changed from city or
Not found – 8
with rheumatoid arthritis in
blumenau, considering a
prevalence of 0.5%
Fig. 1 – Diagram.
late the sample size, the formula for estimating the
 for a simple random sample was applied. The fol-
ameters were considered: prevalence of RA = 0.5%
nts), prevalence of exposure and unknown out-
, sampling error = 5%, and confidence level of 95%.
 size calculated was of 286 individuals. The sam-
reporte
sion, d
for su
curren
family
any ag
catego
ing to 
World 
weight
≥30 kg
years 
respec
and rh
titers).
The
with t
the fin
Corp., 
est we
standa
ables, a
variab
ischem
test an
used. A
perform
ied wit
adjust
interva
For
variab
were t
 this article in press as: Gomes RK, et al. Prevalence of ischemic heart dise
 Southern Brazil. Rev Bras Reumatol. 2017. http://dx.doi.org/10.1016/j.rbre.20
on process was carried out by reviewing medical
he basic health units and in the medical specialty
clinic, as well as by identifying patients in the wait-
 the high-cost drug dispensing pharmacy from the
lds visited at least twice without the interviewer
e person, including a weekend visit and another
isit, or in the case of a change of address, or even in
usal on two occasions, were considered as “losses”.
m was composed of 8 medical students from the
ool of the Fundac¸ão Universidade Regional de Blu-
RB), previously trained to carry out a pre-structured
nd, if necessary, to conduct the interview by tele-
nother occasion, and also by a local professor
 Quality control was performed in 20% of the
s when they were interviewed for a second time,
 application of a short questionnaire.
endent variable was the presence of a posi-
 of a coronary ischemic event after a diagnosis
toid arthritis, defined by an acute myocardial
iagnosed by the physician and requiring cardiac
tion for angioplasty or stent implantation, or a
tery bypass graft surgery.
ependent variables were defined as (a) demo-
iables: gender, age in completed years, categorized
 of 20–59 years for adults and of 60 years or
a p-value ≤
remained i
sion of the
investigato
place, of th
factors for 
related to t
mitted to th
de São Pau
respectivel
study signe
Results
On the who
ity were wo
of 56.6 ± 11
ease durati
The mean 
with a per
4.4% (95% 
prevalent d
≥60 years. 
ence of trad
diabetic pa
ase and associated factors in patients with rheumatoid
tes mellitus or dyslipidemia, or use of medications
iseases; previous or current smoking; prior and
actice of leisure-time physical activity; positive
ory for heart attack or cardiac catheterization at
other, father, brothers or sisters); dichotomous
ion; current body mass index – BMI (kg/m2) accord-
ht and height and categorized according to the
lth Organization recommendations (low/normal
.9 kg/m2, overweight 25–29.9 kg/m2, and obesity
; and (c) RA-related variables: disease duration in
presence of rheumatoid factor, both categorized
y between 0–10 or 11 or more years of disease,
atoid factor <60 (negative or low titer) or >60 (high
 were entered in a system developed for this study
output in the Excel
®
table format; subsequently,
le was exported to the Stata 10.0 program (Stata
ge Station, United States). The variables of inter-
alyzed for their distributions; for this end, mean,
viation and median were used for continuous vari-
requency and percentage were used for categorical
o test the association between history of a coronary
ent and independent variables, the Fisher’s exact
here appropriate, the Wald’s linear trend test were
 that, a multivariate logistic regression analysis was
 aiming to verify the association of the factors stud-
e dependent variable, with estimates of gross and
ds ratios (OR) and of the respective 95% confidence
entry into the final multivariate model, all the
ith a p-value < 0.20 in the univariate analysis
 into account. Those variables that maintained
 0.05 or which were adjusted to the final model
n the multivariate regression model. For the inclu-
 variables in the logistic regression model, the
rs opted sequentially by the inclusion, in the first
e demographic variables; then, the traditional risk
coronary artery disease, and finally the variables
he disease were included. This research was sub-
e Research Ethics Committee of the Universidade
lo (USP) and FURB (protocols 339/13 and 133/12,
y), having obtained approval. All participants in this
d an informed consent form.
le, 296 RA patients were interviewed. The major-
men (83.1%) and adults (60.8%), with a mean age
.7 years, ranging from 25 to 91 years, and with dis-
on of 11.3 ± 9.2 years, ranging from 1 to 51 years.
BMI was 26.4 ± 4.7 kg/m2. The prevalence of MI
cutaneous or surgical reperfusion procedure was
CI 2.0–6.7). In the descriptive analysis, the most
emographic variables were female gender and age
The majority of cases were related to the pres-
itional risk factors, with greater relevance among
rticipants (14.7%). Regarding the characteristics
17.01.006
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Table 1 – Description of the sample and prevalence of acute myocardial infarction according to the independent variables
in patients with rheumatoid arthritis. Blumenau, Santa Catarina, Brazil, 2014.
Variables 
Preva
Total 4
Gender (n =
Male 4
Female 4
Age in years
20–59 (ad 3
≥60 (elde 5
Hypertensio
No 1
Yes7
Diabetes Me
No 
Yes 
Dyslipidemi
No 
Yes 
Body mass i
≤24.9 
25–29.9 
≥30 
Smoking (n 
Never sm
Previous
Physical leis
Never pr
Practiced
Positive fam
No 
Yes 
Disease dur
0–10 yea
≥11 year
Presence of 
0–60 (neg
≥61 (high
a Fischer’s
b Wald’s li
related to R
variable to 
(Table 1).
In the g
variable pr
emia and 
observed w
duration. In
lost the po
the final m
duration. T
8.2-fold in
compared 
disease (Ta
coefficient 
Sample 
n % 
296 100.0 
 296) 
50 16.9 
246 83.1
 (n = 296)
ults) 180 60.8 
rly) 116 39.2 
n (n = 296) 
164 55.4 
132 44.6 
llitus (n = 296) 
 this article in press as: Gomes RK, et al. Prevalence of ischemic heart dise
 Southern Brazil. Rev Bras Reumatol. 2017. http://dx.doi.org/10.1016/j.rbre.2
262 88.5 3
34 11.5 14
a (n = 296) 
223 75.3 3
73 24.7 8
ndex (kg/m2) (n = 296)
113 38.1 3
124 41.9 4
59 20 6
= 296) 
oked 167 56.4 2
 and/or current smokers 129 43.6 6
ure activity (n = 288) 
acticed 114 39.6 3
 and/or practices 174 60.4 6
ily history (n = 296) 
169 57.1 2
127 42.9 6
ation (n = 296) 
rs 175 59.1 1
s 121 40.9 9
rheumatoid factor (n = 266) 
ative, or low titers) 164 61.6 4
 titers) 102 38.4 4
 exact test.
near trend test.
A, duration of disease over 10 years was the only
demonstrate a statistically significant association
ross analysis, it was verified that the dependent
esented a tendency of association with dyslipid-
smoking; on the other hand, significance was
ith hypertension, diabetes mellitus, and disease
 the adjusted analysis, the variable hypertension
wer of association; thus, it was suppressed from
odel, composed of diabetes mellitus and disease
hese two variables presented, respectively, 3.5- and
creases in the chance of showing the outcome,
to non-diabetic patients with less than 10 years of
ble 2). Together, these two variables established a
of determination of 17%.
Discussio
The study i
catheteriza
coronary a
mellitus an
In Brazil
MI (4.4%) in
European c
Kingdom) a
(Morocco) t
wan) to 5%
3.7 to 5% i
from 2% (A
America.11
Acute myocardial infarction p-Value
lence (%) CI 95%
.4 (2.0–6.7)
0.619a
.0 (1.5–9.5)
.4 (1.8–7.0)
0.400a
.8 (1.0–6.7)
.1 (1.1–9.2)
0.017a
.8 (0.2–3.8)
.5 (3.0–12.5)
0.010a
ase and associated factors in patients with rheumatoid
017.01.006
.0 (0.9–5.1)
.7 (2.5–26.8)
0.071a
.1 (0.8–5.4)
.2 (1.8–14.5)
0.364b
.5 (0.8–6.9)
.0 (0.5–7.5)
.7 (0.1–13.2)
0.053a
.3 (0.5–4.7)
.9 (2.5–11.4)
0.214a
.4 (0.7–6.1)
.1 (1.6–10.5)
0.136a
.9 (0.3–5.5)
.2 (2.0–10.5)
0.001a
.1 (0.4–2.7)
.0 (3.9–14.2)
0.603a
.8 (1.5–8.2)
.9 (0.6–9.1)
n
dentified a greater chance of MI defined by cardiac
tion for angioplasty or stent implantation or for
rtery bypass grafting in RA patients with diabetes
d over 10 years of disease.
, this is the first study to establish the prevalence of
 this population. Previous studies have shown that
ountries have a prevalence between 2% (United
nd 7% (Germany and the Netherlands)11; from 1%
o 3% (Egypt) in African countries11; from 2% (Tai-
 (Japan and Russia) in Asian countries11,22; from
n North America (United States)10,11; and finally
rgentina and Venezuela) to 7% (Uruguay) in Latin
,23 On the other hand, a review of the literature for
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Table 2 – Gross and adjusted logistic regression analysis of patients with acute myocardial infarction and independent
variables in patients with rheumatoid arthritis. Blumenau, Santa Catarina, Brazil, 2014.
Variables 
Total p-Val
Gender 0.882
Male 
Female 
Age in years 0.600
20–59 (ad
≥60 (elde
Hypertensio 0.027
No 
Yes 
Diabetes Me 0.005
No 
Yes 
Dyslipidemi
No 
Yes 
Body mass i
≤24.9 
25–29.9 
≥30 
Smoking
Never sm
Previous 
Physical leis
Never pr
Practiced
Positive fam
No 
Yes 
Disease dur
0–10 year
≥11 year
Presence of 
0–60 (neg
≥61 (high
a Excluded
b Excluded
CVD limite
tant preval
a study usin
established
The COR
risk of isch
6.5). The sa
from our s
difference i
a tendency
significance
common to
multivariat
to age.
Among 
of hyperten
Gross analysis 
OR CI 95% 
1.0 
1.1 (0.2–5.2) 
ults) 1.0
rly) 1.3 (0.4–4.1)
n 
1.0 
4.3 (1.1–16.3) 
llitus
1.0 
5.4 (1.6–17.8) 
 this article in press as: Gomes RK, et al. Prevalence of ischemic heart dise
 Southern Brazil. Rev Bras Reumatol. 2017. http://dx.doi.org/10.1016/j.rbre.20
a 0.076
1.0 
2.7 (0.8–8.5) 
ndex (kg/m2) 0.367
1.0 
1.1 (0.2–4.3) 
1.9 (0.4–8.2) 
oked 1.0 0.068
and/or current smokers 3.5 (0.9–10.1) 
ure activity 0.288
acticed 1.0 
 and/or practices 1.8 (0.5–5.5) 
ily history 0.175
1.0 
2.2 (0.7–6.9) 
ation 0.005
s 1.0 
s 8.6 (1.8–39.7) 
rheumatoid factor 0.993
ative, or low titers) 1.0 
 titers) 1.0 (0.3–3.1) 
 from the multiple analysis (p > 0.20).
 from the final model (p > 0.05).
d to Latin American countries found a more impor-
ence (9%) of coronary artery disease.24 In Oceania,
g the hospital database of the city of Christchurch
 a prevalence of 8.3%.15
ONNA10 study found a significant difference in the
emic events among women (RR 3.1) versus men (RR
mple consisted of 75% of women, which differs
tudy, with 83% of women. This could explain the
n results between genders. The age factor showed
 of greater chance among the elderly, but without
. In this study, results were obtained that were
 those in the QUEST-RA study,12 which, after the
e analysis for MI, showed no difference in relation
the traditional risk factors, patients with a history
sion or dyslipidemia did not show a greater chance
of MI becau
in the fina
although th
tional stud
Diabetes
ischemic ev
A systemic
diovascular
in 2014 ind
propensity
while in th
found.
Other st
and physic
diac morbid
ated among
Adjusted analysis
ue OR CI 95% p-Value
a 0.864
1.0
1.0 (0.4–2.3)
a 0.595
1.0
1.3 (0.4–4.1)
 0.116b
1.0
3.0 (0.7–12.4)
0.006
1.0
3.5 (1.7–21.2)
ase and associated factors in patients with rheumatoid
17.01.006
 0.379b
1.0
1.7 (0.5–6.0)
a 0.846
1.0
1.0 (0.2–3.6)
1.1 (0.2–5.4)
 1.0 0.108b
2.7 (0.8–9.1)
a 0.399
1.0
1.6 (0.5–5.0)
 0.221b
1.0
2.0 (0.6–6.5)
 0.005
1.0
8.2 (1.9–43.6)
a 0.946
1.0
1.0 (0.2–3.2)
se, after the analysis adjusted for gender and age
l model, they lost an association with outcome,
is association was pointed out by other interna-
ies.25,26
 mellitus presents a direct association with an
ent, a finding also observed in other studies.12,25
 review and meta-analysis on the impact of car-
 risk factors for MI in patients with RA performed
icated that diabetic individuals demonstrated a
 1.9 times higher versus non-diabetic patients,26
e present study a 3.5 times higher chance was
udies have confirmed that the risk factors obesity
al activity were not associated with ischemic car-
ity.8,12,27 In a French hospital, smoking was evalu-
 patients with RA in association with an ischemic
Please cite t dise
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6 r e v b r a s r e u m a t o l . 2 0 1 7;x x x(x x):xxx–xxx
outcome.28 The investigators found that there was no associ-
ation with CVD, a finding in line with the results of our study.
There was a
sample, bu
while two o
Patients
higher cha
of their dis
adjusted an
study inclu
pital over a
was an ind
This findin
matory pro
atheroscler
hand, a stu
a differenc
duration of
In this s
titers was u
RF is a pred
it could pr
plaque into
that the pr
and in pat
However, t
ation of RF
study.14
In the 
into accoun
it impossib
exploratory
obtained,t
in cross-se
consider is
of some in
characteris
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Funding
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Conflicts of interest
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riel S
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 this article in press as: Gomes RK, et al. Prevalence of ischemic hear
 prevalence of 43% for positive family history in the
t with no statistical significance with the outcome,
ther studies indicated an opposed relationship.29,30
 with disease duration over 10 years had an 8.2-fold
nce of MI versus patients with a shorter duration
ease. This association was maintained after the
alysis and remained in the final model. A Japanese
ding a follow-up of 571 patients in a university hos-
 decade concluded that disease duration (>10 years)
ependent risk factor for cardiovascular events.31
g results from the longer duration of the inflam-
cess for the generation of consequences such as
osis and endothelial dysfunction.32 On the other
dy conducted in the Netherlands did not indicate
e in the risk for an ischemic event due to a disease
 less than or greater than 10 years.33
tudy, the value of the rheumatoid factor (RF) in high
sed as a marker of poor prognosis (RF > 60), because
ictor of cardiovascular disease34 and also because
omote instability and rupture of atherosclerotic
 the coronary artery.35 Some studies have shown
esence of RF in both non-diseased individuals36
ients with RA37 confers a higher chance of MI.
he results of this study did not show any associ-
 with the outcome, as already indicated in another
present study, some limitations must be taken
t. The cross-sectional design of the study makes
le to determine cause and effect between the
 variables and the outcome. Based on the results
he possibility of reverse causality, characteristic
ctional studies, is highlighted. Another factor to
 the possibility of memory bias in the collection
formation, which is attenuated by the common
tic of RA being a chronic illness. Finally, the self-
ta on comorbidities have not been confirmed by
. On the other hand, health surveys reveal that
ation obtained on the prevalence of chronic dis-
nts good agreement, when compared to medical
linical exams, especially for some chronic diseases
ertension and diabetes mellitus (DM).38,39 It should
considered that the data related to RA were col-
rding to the European League Against Rheumatism
ommendations for annual detection and monitor-
iovascular risk.40
he first Brazilian study to establish a prevalence of
A patients. Among the traditional risk factors, dia-
tus, and among factors related to RA, disease dura-
the associated variables. New population-based
 needed in order to increase the consistency of
n on coronary artery disease in RA patients and also
te associated factors in other Brazilian regions.
e Amparo à Pesquisa do Estado de São Paulo, pro-
P 2013/12979-1.
The au
Ackn
To Drs
imo S.
with p
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2. Gui
Le 
200
3. Cro
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glo
201
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5. Ma
Rad
pre
pop
6. Sen
RM
usi
7. Lév
risk
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lite
8. Ma
VL,
dis
pop
200
9. Ber
mo
pat
and
200
10. Sol
P, e
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of r
201
11. Dou
MH
and
inte
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12. Nar
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dis
the
13. Hol
Ran
isch
art
rhe
200
 Southern Brazil. Rev Bras Reumatol. 2017. http://dx.doi.org/10.1016/j.rbre.2
ase and associated factors in patients with rheumatoid
s declare no conflicts of interest.
edgements
 Maria Gallo, João Elias de Moura Júnior and Jeron-
ites Júnior, the rheumatologists who contributed
ts to obtain the study sample.
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17.01.006Prevalence of ischemic heart disease and associated factors in patients with rheumatoid arthritis in Southern Brazil
	Introduction
	Materials and methods
	Results
	Discussion
	Funding
	Conflicts of interest
	Acknowledgements
	References