Rheumatology Advance Access published February 8, 2016
RHEUMATOLOGY
53
Letter to the Editor (other) doi:10.1093/rheumatology/kew002
Chronic kidney disease reduces risk of cardiovascular disease in patients with rheumatoid arthritis according to the QRISK lifetime cardiovascular risk calculator
.
QRISK lifetime appears to inaccurately calculate the cardiovascular disease risk for RA patients with chronic kidney disease.
SIR, the QRISK lifetime cardiovascular risk calculator (QRISK lifetime) is based on data from 2.3 million British persons and provides an estimate of lifetime risk of cardiovascular disease (CVD) [1]. The QRISK lifetime equation is available as an online calculator (www.qrisk. org/lifetime/) and as open source software. Based on traditional CVD risk factors and the presence of certain diagnoses that entail high CVD risk, including RA and chronic kidney disease (CKD) [2, 3], the QRISK lifetime
TABLE 1 QRISK lifetime cardiovascular risk calculator estimates across four scenarios
BP Normal BP, 120 mmHg
Elevated BP, 180 mmHg
Age (years)
Healthy (%)
30 35 40 45 50 55 60 65 70 75 80 84 30 35 40 45 50 55 60 65 70 75 80 84
31.0 (4) 31.0 (4) 31.0 (4) 30.8 (4) 30.5 (4) 29.8 (4) 28.6 (4) 26.9 (2) 24.7 (2) 21.9 (2) 18.4 (2) 15.2 (2) 38.7 (3) 38.8 (4) 38.7(4) 38.6 (4) 38.1 (4) 37.3 (4) 36.0 (2) 33.9 (2) 31.3 (2) 27.9 (2) 23.6 (2) 19.8 (2)
RA, non-CKD (%) 33.1 33.2 33.2 33.1 32.7 31.9 30.6 28.6 26.2 23.1 19.5 16.5 40.8 40.9 41.0 40.8 40.4 39.5 38.0 35.6 32.8 29.1 24.8 21.2
(1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1)
Female Non-RA, CKD (%) 31.5 31.6 31.6 31.5 31.1 30.3 29.0 26.9 24.4 21.4 18.0 15.4 38.8 38.9 39.0 38.9 38.4 37.5 35.9 33.5 30.6 26.9 22.8 19.7
(2) (3) (3) (3) (3) (3) (3) (2) (3) (3) (3) (3) (2) (2) (2) (2) (3) (3) (4) (3) (3) (3) (3) (3)
RA, CKD (%) 31.5 31.7 31.9 31.8 31.4 30.6 29.1 26.7 24.0 20.7 17.2 14.9 38.6 38.9 39.1 39.0 38.6 37.6 35.9 33.1 29.9 26.0 21.8 18.9
(2) (2) (2) (2) (2) (2) (2) (4) (4) (4) (4) (4) (4) (2) (2) (2) (2) (2) (4) (4) (4) (4) (4) (4)
Healthy (%) 26.5 26.5 26.5 26.4 26.2 25.7 25.1 24.0 22.5 20.2 17.2 14.1 36.2 36.2 36.1 36.0 35.7 35.2 34.3 33.0 31.0 28.1 24.2 20.0
(3) (3) (3) (3) (3) (3) (3) (3) (2) (2) (2) (2) (3) (3) (3) (3) (3) (3) (3) (3) (3) (2) (2) (2)
RA, non-CKD (%) 29.9 29.9 29.9 29.8 29.6 29.1 28.3 27.1 25.4 22.9 19.6 16.3 40.2 40.3 40.3 40.1 39.8 39.3 38.3 36.8 34.7 31.5 27.3 23.0
(1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1)
Non-RA, RA, CKD CKD (%) (%) 26.1 26.1 26.1 26.1 25.8 25.4 24.7 23.5 21.9 19.5 16.6 13.9 35.5 35.5 35.6 35.5 35.2 34.7 33.8 32.3 30.3 27.2 23.4 19.8
(4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4)
26.8 26.9 27.0 27.0 26.7 26.3 25.5 24.2 22.5 19.9 16.7 14.0 36.3 36.4 36.5 36.5 36.3 35.7 34.8 33.2 31.0 27.7 23.6 20.0
(2) (2) (2) (2) (2) (2) (2) (2) (2) (3) (3) (3) (2) (2) (2) (2) (2) (2) (2) (2) (2) (3) (3) (2)
L ET T E R
Male
Numbers in parenthesis signify rank from highest (1) to lowest (4) risk estimates within the age group. BP: blood pressure; CKD: chronic kidney disease.
! The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://rheumatology.oxfordjournals.org/ at Universitätsbibliothek Osnabrück on February 13, 2016
Rheumatology key message
estimates a person’s lifetime risk of CVD [1]. The use of QRISK lifetime is recommended alongside short term (10-year) CVD risk prediction in the 2014 Joint British Society consensus recommendations for CVD prevention [4], but it has not been validated in RA cohorts. Our aim was to evaluate the QRISK lifetime risk estimates for patients with and without RA and CKD. Using the online version of QRISK lifetime, we calculated the CVD risk for a generic, white, non-smoking, non-diabetic person without previous CVD, atrial fibrillation, premature family history of CVD or use of antihypertensive medication. The person was 75 kg, 175 cm and had a total cholesterol/high-density lipoprotein cholesterol ratio of 4.0. We defined four scenarios for the generic patient: healthy (non-RA, non-CKD); RA, non-CKD; non-RA, CKD; and RA and CKD. For each scenario, we calculated the QRISK lifetime risk at 5 year intervals from 30 (lower age limit) to 84 years (upper age limit). This procedure was undertaken for both sexes and for normal (120 mmHg) and elevated systolic blood pressure (sysBP) (180 mmHg). The QRISK lifetime estimates were consistently highest for RA patients without CKD, regardless of age, sex and
1
Letter to the Editor
Acknowledgements The authors thank Tore K. Kvien and Inge C. Olsen for valuable comments and scientific advice. Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.
2
Disclosure statement: A.G.S. has received speaker honoraria and/or consulting fee from Merck/Schering-Plough, Abbott, BMS, UCB, Pfizer/Wyeth, Eli Lilly, Genentec and Hoffmann-La Roche. All other authors have declared no conflicts of interest.
Eirik Ikdahl1, Silvia Rollefstad1, Grunde Wibetoe1 and Anne Grete Semb1 1
The Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway Revised version accepted 7 January 2016 Correspondence to: Eirik Ikdahl, Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vinderen, N-0319 Oslo, Norway. E-mail: [email protected]
References 1 Hippisley-Cox J, Coupland C, Robson J, Brindle P. Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ 2010;341:6624. 2 Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296305. 3 Maradit-Kremers H, Nicola PJ, Crowson CS, Ballman KV, Gabriel SE. Cardiovascular death in rheumatoid arthritis: a population-based study. Arthritis Rheum 2005;52: 72232. 4 JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014;100 (Suppl 2):167. 5 Sihvonen S, Korpela M, Mustonen J, Laippala P, Pasternack A. Renal disease as a predictor of increased mortality among patients with rheumatoid arthritis. Nephron Clinical Pract 2004;96:10714. 6 Chiu HY, Huang HL, Li CH et al. Increased risk of chronic kidney disease in rheumatoid arthritis associated with cardiovascular complications A National PopulationBased Cohort Study. PloS One 2015;10:0136508. 7 Hickson LJ, Crowson CS, Gabriel SE, McCarthy JT, Matteson EL. Development of reduced kidney function in rheumatoid arthritis. Am J Kidney Dis 2014;63:20613.
www.rheumatology.oxfordjournals.org
Downloaded from http://rheumatology.oxfordjournals.org/ at Universitätsbibliothek Osnabrück on February 13, 2016
sysBP (Table 1). If the patient had RA and CKD, the estimated lifetime risk was persistently lower compared with RA patients without CKD. For male patients >65 years (with normal sysBP) and >60 years (with elevated sysBP) QRISK lifetime generated the lowest estimates for RA patients with CKD of all scenarios. In fact, for patients >65 years with high sysBP, QRISK lifetime yields lower CVD risk estimates for males with both RA and CKD compared with healthy females. Females without RA and with CKD had the lowest lifetime risk compared with all other scenarios (healthy, RA + non-CKD and RA + CKD). RA and CKD are conditions that are associated with increased risk of CVD [2, 3]. It has previously been reported that RA patients have a relatively high prevalence of CKD, and that the coexistence of these two conditions is associated with increased risk of CVD morbidity and mortality compared with RA patients with normal kidney function [57]. However, our analyses reveal that QRISK lifetime consistently yields lower CVD risk estimates for RA patients with CKD compared with RA patients without CKD. It was not possible to evaluate the statistical explanation for this paradoxical effect since the QRISK lifetime algorithm is not currently available in written form. However, since our observations indicate that QRISK lifetime may perform suboptimally for subgroups of RA patients, we argue that evidence on longitudinal performance, including external validation, of the calculator is necessary before it can be applied in clinical decision making for RA patients. Our results also indicate that QRISK lifetime in particular underestimates the risk for middle-aged males with RA and CKD. Accordingly, our findings are in line with the Joint British Society consensus recommendations for CVD prevention, which underlines that the QRISK lifetime is especially aimed at younger patients, females and patients with low estimated CVD risk [4]. In conclusion, QRISK lifetime appears to inaccurately calculate the CVD risk for RA patients with CKD. We argue that evidence on the performance and external validation of QRISK lifetime is needed before it can be applied to guide clinical decision making for RA patients.
RHEUMATOLOGY
53
Letter to the Editor (other) doi:10.1093/rheumatology/kew002
Chronic kidney disease reduces risk of cardiovascular disease in patients with rheumatoid arthritis according to the QRISK lifetime cardiovascular risk calculator
.
QRISK lifetime appears to inaccurately calculate the cardiovascular disease risk for RA patients with chronic kidney disease.
SIR, the QRISK lifetime cardiovascular risk calculator (QRISK lifetime) is based on data from 2.3 million British persons and provides an estimate of lifetime risk of cardiovascular disease (CVD) [1]. The QRISK lifetime equation is available as an online calculator (www.qrisk. org/lifetime/) and as open source software. Based on traditional CVD risk factors and the presence of certain diagnoses that entail high CVD risk, including RA and chronic kidney disease (CKD) [2, 3], the QRISK lifetime
TABLE 1 QRISK lifetime cardiovascular risk calculator estimates across four scenarios
BP Normal BP, 120 mmHg
Elevated BP, 180 mmHg
Age (years)
Healthy (%)
30 35 40 45 50 55 60 65 70 75 80 84 30 35 40 45 50 55 60 65 70 75 80 84
31.0 (4) 31.0 (4) 31.0 (4) 30.8 (4) 30.5 (4) 29.8 (4) 28.6 (4) 26.9 (2) 24.7 (2) 21.9 (2) 18.4 (2) 15.2 (2) 38.7 (3) 38.8 (4) 38.7(4) 38.6 (4) 38.1 (4) 37.3 (4) 36.0 (2) 33.9 (2) 31.3 (2) 27.9 (2) 23.6 (2) 19.8 (2)
RA, non-CKD (%) 33.1 33.2 33.2 33.1 32.7 31.9 30.6 28.6 26.2 23.1 19.5 16.5 40.8 40.9 41.0 40.8 40.4 39.5 38.0 35.6 32.8 29.1 24.8 21.2
(1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1)
Female Non-RA, CKD (%) 31.5 31.6 31.6 31.5 31.1 30.3 29.0 26.9 24.4 21.4 18.0 15.4 38.8 38.9 39.0 38.9 38.4 37.5 35.9 33.5 30.6 26.9 22.8 19.7
(2) (3) (3) (3) (3) (3) (3) (2) (3) (3) (3) (3) (2) (2) (2) (2) (3) (3) (4) (3) (3) (3) (3) (3)
RA, CKD (%) 31.5 31.7 31.9 31.8 31.4 30.6 29.1 26.7 24.0 20.7 17.2 14.9 38.6 38.9 39.1 39.0 38.6 37.6 35.9 33.1 29.9 26.0 21.8 18.9
(2) (2) (2) (2) (2) (2) (2) (4) (4) (4) (4) (4) (4) (2) (2) (2) (2) (2) (4) (4) (4) (4) (4) (4)
Healthy (%) 26.5 26.5 26.5 26.4 26.2 25.7 25.1 24.0 22.5 20.2 17.2 14.1 36.2 36.2 36.1 36.0 35.7 35.2 34.3 33.0 31.0 28.1 24.2 20.0
(3) (3) (3) (3) (3) (3) (3) (3) (2) (2) (2) (2) (3) (3) (3) (3) (3) (3) (3) (3) (3) (2) (2) (2)
RA, non-CKD (%) 29.9 29.9 29.9 29.8 29.6 29.1 28.3 27.1 25.4 22.9 19.6 16.3 40.2 40.3 40.3 40.1 39.8 39.3 38.3 36.8 34.7 31.5 27.3 23.0
(1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1) (1)
Non-RA, RA, CKD CKD (%) (%) 26.1 26.1 26.1 26.1 25.8 25.4 24.7 23.5 21.9 19.5 16.6 13.9 35.5 35.5 35.6 35.5 35.2 34.7 33.8 32.3 30.3 27.2 23.4 19.8
(4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4) (4)
26.8 26.9 27.0 27.0 26.7 26.3 25.5 24.2 22.5 19.9 16.7 14.0 36.3 36.4 36.5 36.5 36.3 35.7 34.8 33.2 31.0 27.7 23.6 20.0
(2) (2) (2) (2) (2) (2) (2) (2) (2) (3) (3) (3) (2) (2) (2) (2) (2) (2) (2) (2) (2) (3) (3) (2)
L ET T E R
Male
Numbers in parenthesis signify rank from highest (1) to lowest (4) risk estimates within the age group. BP: blood pressure; CKD: chronic kidney disease.
! The Author 2016. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: [email protected]
Downloaded from http://rheumatology.oxfordjournals.org/ at Universitätsbibliothek Osnabrück on February 13, 2016
Rheumatology key message
estimates a person’s lifetime risk of CVD [1]. The use of QRISK lifetime is recommended alongside short term (10-year) CVD risk prediction in the 2014 Joint British Society consensus recommendations for CVD prevention [4], but it has not been validated in RA cohorts. Our aim was to evaluate the QRISK lifetime risk estimates for patients with and without RA and CKD. Using the online version of QRISK lifetime, we calculated the CVD risk for a generic, white, non-smoking, non-diabetic person without previous CVD, atrial fibrillation, premature family history of CVD or use of antihypertensive medication. The person was 75 kg, 175 cm and had a total cholesterol/high-density lipoprotein cholesterol ratio of 4.0. We defined four scenarios for the generic patient: healthy (non-RA, non-CKD); RA, non-CKD; non-RA, CKD; and RA and CKD. For each scenario, we calculated the QRISK lifetime risk at 5 year intervals from 30 (lower age limit) to 84 years (upper age limit). This procedure was undertaken for both sexes and for normal (120 mmHg) and elevated systolic blood pressure (sysBP) (180 mmHg). The QRISK lifetime estimates were consistently highest for RA patients without CKD, regardless of age, sex and
1
Letter to the Editor
Acknowledgements The authors thank Tore K. Kvien and Inge C. Olsen for valuable comments and scientific advice. Funding: No specific funding was received from any funding bodies in the public, commercial or not-for-profit sectors to carry out the work described in this manuscript.
2
Disclosure statement: A.G.S. has received speaker honoraria and/or consulting fee from Merck/Schering-Plough, Abbott, BMS, UCB, Pfizer/Wyeth, Eli Lilly, Genentec and Hoffmann-La Roche. All other authors have declared no conflicts of interest.
Eirik Ikdahl1, Silvia Rollefstad1, Grunde Wibetoe1 and Anne Grete Semb1 1
The Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway Revised version accepted 7 January 2016 Correspondence to: Eirik Ikdahl, Preventive Cardio-Rheuma Clinic, Department of Rheumatology, Diakonhjemmet Hospital, PO Box 23, Vinderen, N-0319 Oslo, Norway. E-mail: [email protected]
References 1 Hippisley-Cox J, Coupland C, Robson J, Brindle P. Derivation, validation, and evaluation of a new QRISK model to estimate lifetime risk of cardiovascular disease: cohort study using QResearch database. BMJ 2010;341:6624. 2 Go AS, Chertow GM, Fan D, McCulloch CE, Hsu CY. Chronic kidney disease and the risks of death, cardiovascular events, and hospitalization. N Engl J Med 2004;351:1296305. 3 Maradit-Kremers H, Nicola PJ, Crowson CS, Ballman KV, Gabriel SE. Cardiovascular death in rheumatoid arthritis: a population-based study. Arthritis Rheum 2005;52: 72232. 4 JBS3 Board. Joint British Societies’ consensus recommendations for the prevention of cardiovascular disease (JBS3). Heart 2014;100 (Suppl 2):167. 5 Sihvonen S, Korpela M, Mustonen J, Laippala P, Pasternack A. Renal disease as a predictor of increased mortality among patients with rheumatoid arthritis. Nephron Clinical Pract 2004;96:10714. 6 Chiu HY, Huang HL, Li CH et al. Increased risk of chronic kidney disease in rheumatoid arthritis associated with cardiovascular complications A National PopulationBased Cohort Study. PloS One 2015;10:0136508. 7 Hickson LJ, Crowson CS, Gabriel SE, McCarthy JT, Matteson EL. Development of reduced kidney function in rheumatoid arthritis. Am J Kidney Dis 2014;63:20613.
www.rheumatology.oxfordjournals.org
Downloaded from http://rheumatology.oxfordjournals.org/ at Universitätsbibliothek Osnabrück on February 13, 2016
sysBP (Table 1). If the patient had RA and CKD, the estimated lifetime risk was persistently lower compared with RA patients without CKD. For male patients >65 years (with normal sysBP) and >60 years (with elevated sysBP) QRISK lifetime generated the lowest estimates for RA patients with CKD of all scenarios. In fact, for patients >65 years with high sysBP, QRISK lifetime yields lower CVD risk estimates for males with both RA and CKD compared with healthy females. Females without RA and with CKD had the lowest lifetime risk compared with all other scenarios (healthy, RA + non-CKD and RA + CKD). RA and CKD are conditions that are associated with increased risk of CVD [2, 3]. It has previously been reported that RA patients have a relatively high prevalence of CKD, and that the coexistence of these two conditions is associated with increased risk of CVD morbidity and mortality compared with RA patients with normal kidney function [57]. However, our analyses reveal that QRISK lifetime consistently yields lower CVD risk estimates for RA patients with CKD compared with RA patients without CKD. It was not possible to evaluate the statistical explanation for this paradoxical effect since the QRISK lifetime algorithm is not currently available in written form. However, since our observations indicate that QRISK lifetime may perform suboptimally for subgroups of RA patients, we argue that evidence on longitudinal performance, including external validation, of the calculator is necessary before it can be applied in clinical decision making for RA patients. Our results also indicate that QRISK lifetime in particular underestimates the risk for middle-aged males with RA and CKD. Accordingly, our findings are in line with the Joint British Society consensus recommendations for CVD prevention, which underlines that the QRISK lifetime is especially aimed at younger patients, females and patients with low estimated CVD risk [4]. In conclusion, QRISK lifetime appears to inaccurately calculate the CVD risk for RA patients with CKD. We argue that evidence on the performance and external validation of QRISK lifetime is needed before it can be applied to guide clinical decision making for RA patients.
