Metabolic Syndrome, Its Relationship with Disease Activity and Cardiovascular Risk in a Cohort of Patients with Rheumatoid Arthritis

Research Article

Austin J Cardiovasc Dis Atherosclerosis. 2016; 3(1): 1021.

Metabolic Syndrome, Its Relationship with Disease Activity and Cardiovascular Risk in a Cohort of Patients with Rheumatoid Arthritis

Batún JAJ1*, García OA1 and Salas M2

1Department of Internal Medicine, Regional High Specialty Hospital, Dr Gustavo A. Rovirosa Pérez, Villahermosa, Tabasco, México

2Universidad Juárez Autónoma de Tabasco, Villahermosa, Tabasco, México

*Corresponding author: Batún JAJ, Departamento de Medicina Interna, Hospital Regional de Alta Especialidad, Dr Gustavo A. Rovirosa Pérez, Villahermosa, Tabasco, México

Received: May 10, 2016; Accepted: May 30, 2016; Published: June 01, 2016


Background: There is a high prevalence of metabolic syndrome in rheumatoid arthritis patients, which also participates in the increase of cardiovascular risk.

Objective: To determine the frequency of metabolic syndrome in a cohort of patients with rheumatoid arthritis and its relationship with disease activity and cardiovascular risk factors.

Methods: We studied 166 patients diagnosed with rheumatoid arthritis according to the ACR/EULAR 2010 criteria. Disease activity was evaluated by means of the DAS-28 CRP work tool, and the presence of metabolic syndrome was established in accordance with the NECP ATP-III criteria.

Results: The 51,8% had metabolic syndrome (53,5% of the women and 22,2% of the men). The main alteracions were abdominal circumference increased (68,1%), hypoalphalipoproteinemia (60,2%) and hypertriglyceridemia (55,4%). It was observed that patients with a greater disease activity were more likely to experience metabolic syndrome. A DAS-28 CRP ≥ 2,3 was associated independently with the development of metabolic syndrome (RR 1,23; IC 1,64- 2,35; p 0,028); on the other hand, the use of methotrexate was independently associated with the absence of metabolic syndrome (RR 0,43; IC 0.19-0,96; P 0,04). We found a significant difference between disease activity and systolic blood pressure ≥ 130 mmHg (p 0,018), hypoalphalipoproteinemia (p 0,001) and hypertriglyceridemia (p 0,003).

Conclusion: There is a high frequency of metabolic syndrome in patients with rheumatoid arthritis which can be associated to disease activity; in so much as it may be related to an increased systolic hypertension, hypertriglyceridemia and hypoalphalipoproteinemia.

Keywords: Cardiovascular risk; Metabolic syndrome; Rheumatoid arthritis


Metabolic Syndrome (MS) is the term used to refer to a set of cardiovascular risk factors, within its definition includes elevated triglycerides, low levels of High Density Lipoprotein (c-HDL), central obesity, hypertension and insulin resistance [1]. Since its first definition by the World Health Organization in 1999 [2] there were proposed five different diagnostic criteria, using the same variables but with differences in their ranks and their measurement criteria. Being the most used in epidemiological studies the European Group for the Study of Insulin Resistance (EGIR) [3] elaborated in 2001 and modified in the 2005 by the National Cholesterol Education Program Adult Treatment Panel III l (NCEP ATP III) [4]. Rheumatoid Arthritis (RA) is a systemic, inflammatory, autoimmune and chronic disease, characterized by commitment of the synovial with inflammation and hyperplasia, showing destruction of cartilage and bone, as well as affectation mainly extra-articular eye level, cardiovascular and pulmonary [5,6]. Patients with RA have a higher cardiovascular risk than the general population, a risk comparable with that of patients with diabetes mellitus, because chronic inflammation leads to a process of accelerated atherosclerosis [7]. Likewise they have a higher prevalence of hypertension, obesity and MS [8].

Modifying Antirheumatic Drugs Disease (DMARDs) and corticosteroids, in addition to produce disease control and mitigate inflammation, have effects that can decrease or increase the factors of traditional cardiovascular risk such as dyslipidemia, hypertension and resistance insulin and thus favors the development of MS. It has been observed that methotrexate has cardioprotective effects, reducing mortality, decreases the values of c-HDL, triglycerides and the risk of MS [9,10]. Glucocorticoids cause alterations in lipid profile with increased levels of triglycerides and total cholesterol, likewise have been associated with elevation of blood pressure, obesity, hyperglycemia and insulin resistance, which increases the risk of suffer MS [11,12]. Antimalarial drugs have been associated with improved lipid profile, with decreased levels of total cholesterol, Low- Density Lipoprotein (c-LDL) and triglycerides [13]. Leflunomide has been associated with elevation tensional levels and elevated triglycerides and total cholesterol [10]. Finally it has been observed that azathioprine raises levels of cholesterol LDL, total cholesterol and triglycerides [14]. The aim of this study was to establish the frequency of SM in patients with RA, its relationship with cardiovascular risk factors and disease activity, and its association with the use of DMARDs and glucocorticoids. This is to clarify the relationship of AR, activity and management with the development of SM. We hope to meet one step closer to the establishment of analytical models with which we can determine the best measure cardiovascular risk in this population.

Materials and Methods

A descriptive, transversal and observational study was performed. Patients with RA diagnosis were studied according to the ACR/ EULAR criteria 2010 [15] that consecutively came to the outpatient of the service Rheumatology Regional High Specialty Hospital Dr. Gustavo A Rovirosa Pérez, during the period of January- December 2015.The participation in the study was approved by each patient signed an informed consent, with the prior approval of the Bioethics Committee of the Hospital. It was applied a questionnaire to the participants and a review of clinical records was made and recorded as variables the age, gender, tobacco smokings, carriers of hypertension, diabetes mellitus and use of DMARDs (azathioprine, methotrexate, hydroxychloroquine, leflunomide) and glucocorticoids.

For each patient a sample of 10ml of venous blood in the antecubital region was removed in the morning (8:00-9:00 hrs), with a minimum 10-hour fast prior to obtain results of triglycerides, total cholesterol, c-HDL, C-Reactive Protein (CRP), Erythrocyte Sedimentation Rate (ESR) and glucose. The levels of c-LDL were obtained indirectly through the Friedewald formula.

The weight of the patients was taken with a scale, previously calibrated, barefoot and in light clothing, expressing the results in kilograms. Height was measured with a standard height board with the patient in standing position, expressing the results in meters. With these results the Body Mass Index (BMI) was calculated using the formula weight / height 2 (Kg/m2), classifying the results low weight ranges: <18.5 Kg/m2; normal: 18.5-24.9 Kg/m2; overweight: 25-29.9 Kg/m2; Obesity> 30 Kg/m2.

With the patient in standing position it was measured with a tape measure waist circumference (PA) at umbilical level according to WHO guidelines.

With the patient sitting, after a rest of 20 minutes, blood pressure was taken with a manual mercury sphygmomanometer in the right arm according to the thickness of each patient.

Patients were classified with the presence of SM according to the criteria of the ATP-III 4 requiring the presence of three or more of the following parameters: PA ≥ 88 cm in women and ≥ 102 men, triglycerides ≥ 150 mg / dL, c-HDL ≤ 50 mg / dL in women or ≤ 40 mg / dL in men, fasting glucose ≥ 110 mg / dL, Systolic Blood Pressure (SBP) ≥ 130 mmHg or Diastolic Blood Pressure (DBP) ≥ 85 mmHg or use of a antihypertensive drug.

Factors related to the disease such as the duration of the disease were determined, the disease activity was assessed by DAS-28 CRP classified as remission <2.3, mild ≥ 2.3 to <3.8 activity, moderate activity ≥ 3.8 to <4.9 and serious activity ≥ 4.9. Rheumatoid Factor (RF) positive with values above 15 IU / ml was considered.

Statistic analysis

Statistical analysis using the SPSS 22.0 for Windows was made. Considered significant results in a value of P ≤0.05. Compliance of the normal distribution of variables was assessed using the Kolmogorov- Smirnov test.

Categorical variables were presented as frequencies and percentages and were compared with the Chi square test. Continuous variables were presented as median and interquartile range or mean and standard deviation according the normal distribution, and were compared with the nonparametric Mann-Whitney or Student’s t-test as the case. Finally, a multivariate logistic regression model was used to determine the association of these variables and the MS.


166 patients with the diagnosis of RA, 51,8% of whom had SM, 5,5% of women and 22.2% of men were evaluated. 68,1% had increased waist circumference, 60,2% hypoalphalipoproteinemia, 55,4% hypertriglyceridemia, 31,9% elevated SBP, 27,1% DBP elevated and 21,1% hyperglycemia.

The mean waist circumference was 94,6 ± 13,3, the one for c-HDL was 47,9 ± 11,1, for the triglycerides 201 ± 140,2, mean SBP was 122,9 ± 15,2 , the DBP 77,7 ± 10,8, the total cholesterol was 201,3 ± 38,8 and c-LDL 116,2 ± 34,5. Frequency components MS by gender is observed in the (Figure 1).