Open Access Highly Accessed Open Badges Research article

Cardiovascular disease in patients with rheumatoid arthritis: results from the QUEST-RA study

Antonio Naranjo1*, Tuulikki Sokka2, Miguel A Descalzo3, Jaime Calvo-Alén4, Kim Hørslev-Petersen5, Reijo K Luukkainen6, Bernard Combe7, Gerd R Burmester8, Joe Devlin9, Gianfranco Ferraccioli10, Alessia Morelli10, Monique Hoekstra11, Maria Majdan12, Stefan Sadkiewicz13, Miguel Belmonte14, Ann-Carin Holmqvist15, Ernest Choy16, Recep Tunc17, Aleksander Dimic18, Martin Bergman19, Sergio Toloza20, Theodore Pincus21 and the QUEST-RA Group

Author Affiliations

1 Hospital de Gran Canaria Dr. Negrin, University of Las Palmas de Gran Canaria, Barranco de la Ballena s/n 35011, Spain

2 Jyväskylä Central Hospital, Jyväskylä, and Medcare Oy, Äänekoski, Finland; Jyväskylä Central Hospital, Keskussairaalantie 19, 40620 Jyväskylä, Finland

3 Research Unit, Spanish Foundation of Rheumatology, C/Marqués de Duero, 5, 1°, 28001, Madrid, Spain

4 Hospital Sierrallana, Torrelavega, B°. de Ganzo, s/n 39300, Spain

5 King Christian the Xth Hospital, Toldbodgade 3, 6300 Gråsten, Denmark

6 Satakunta Central Hospital, Rauman aluesairaala, Steniuksenkatu 2, 26100 Rauma, Finland

7 Hôpital Lapeyronie, 371, avenue du Doyen Gaston Giraud 34295 Montpellier Cedex 5, France

8 Charité – University Medicine Berlin, Chariteplatz 1, 10117 Berlin, Germany

9 Waterford Regional Hospital, Dunmore Road, Waterford, Co Waterford, Ireland

10 Catholic University of Sacred Heart, Largo F. Vito, 1 – 00168, Rome, Italy

11 Medisch Spectrum Twente, Haaksbergerstraat 55, 7513 ER, Enschede, The Netherlands

12 Medical University of Lublin, al. Rac3awickie 1, 20-095, Lublin, Poland

13 Szpital Wojewodzki im. Jana Biziela, Ul. Kornela Ujejskiego 65, 85-104 Bydgoszcz, Poland

14 Hospital General de Castellón, Avenida Benicasim S/N 12004 Castellón, Spain

15 Hudiksvall Medical Clinic, 824 81 Hudiksvall, Sweden

16 Kings College Hospital, Strand, London WC2R 2LS UK

17 Meram Medical Faculty, Selcuk University, Konya 42090, Turkey

18 Rheumatology Institut, Srpskih Junaka 2, 18205 Niška Banja, Serbia

19 Taylor Hospital, 175 East Chester Pike, Ridley Park, Pennsylvania, PA 19078USA

20 Hospital San Juan Bautista, Avenida Illia 200, K4700ABO, Catamarca, Argentina

21 New York University Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003, USA

For all author emails, please log on.

Arthritis Research & Therapy 2008, 10:R30  doi:10.1186/ar2383

See related editorial by van Vollenhoven,

Published: 6 March 2008



We analyzed the prevalence of cardiovascular (CV) disease in patients with rheumatoid arthritis (RA) and its association with traditional CV risk factors, clinical features of RA, and the use of disease-modifying antirheumatic drugs (DMARDs) in a multinational cross-sectional cohort of nonselected consecutive outpatients with RA (The Questionnaires in Standard Monitoring of Patients with Rheumatoid Arthritis Program, or QUEST-RA) who were receiving regular clinical care.


The study involved a clinical assessment by a rheumatologist and a self-report questionnaire by patients. The clinical assessment included a review of clinical features of RA and exposure to DMARDs over the course of RA. Comorbidities were recorded; CV morbidity included myocardial infarction, angina, coronary disease, coronary bypass surgery, and stroke. Traditional risk factors recorded were hypertension, hyperlipidemia, diabetes mellitus, smoking, physical inactivity, and body mass index. Unadjusted and adjusted hazard ratios (HRs) (95% confidence interval [CI]) for CV morbidity were calculated using Cox proportional hazard regression models.


Between January 2005 and October 2006, the QUEST-RA project included 4,363 patients from 48 sites in 15 countries; 78% were female, more than 90% were Caucasian, and the mean age was 57 years. The prevalence for lifetime CV events in the entire sample was 3.2% for myocardial infarction, 1.9% for stroke, and 9.3% for any CV event. The prevalence for CV risk factors was 32% for hypertension, 14% for hyperlipidemia, 8% for diabetes, 43% for ever-smoking, 73% for physical inactivity, and 18% for obesity. Traditional risk factors except obesity and physical inactivity were significantly associated with CV morbidity. There was an association between any CV event and age and male gender and between extra-articular disease and myocardial infarction. Prolonged exposure to methotrexate (HR 0.85; 95% CI 0.81 to 0.89), leflunomide (HR 0.59; 95% CI 0.43 to 0.79), sulfasalazine (HR 0.92; 95% CI 0.87 to 0.98), glucocorticoids (HR 0.95; 95% CI 0.92 to 0.98), and biologic agents (HR 0.42; 95% CI 0.21 to 0.81; P < 0.05) was associated with a reduction of the risk of CV morbidity; analyses were adjusted for traditional risk factors and countries.


In conclusion, prolonged use of treatments such as methotrexate, sulfasalazine, leflunomide, glucocorticoids, and tumor necrosis factor-alpha blockers appears to be associated with a reduced risk of CV disease. In addition to traditional risk factors, extra-articular disease was associated with the occurrence of myocardial infarction in patients with RA.