Exercise Echocardiography in Rheumatoid Arthritis: A Case-Control Study Mohammed K. Saghir, MD, Christine Attenhofer Jost, MD, Kenneth J. Warrington, MD, Stephen S. Cha, MS, and Patricia A. Pellikka, MD, FASE, Rochester, Minnesota Background: Rheumatoid arthritis (RA) is associated with increased cardiovascular risk. Methods: To assess the role of exercise echocardiography (EE) in the evaluation of patients with RA, follow-up (mean, 6.7 6 3.7 years) was retrospectively obtained in 159 patients with RA who underwent EE. Patients were matched for age, gender, and cardiovascular risk factors with 454 controls who underwent EE. Results: Patients with RA were more likely to have positive results for ischemia on EE (odds ratio, 2.32; 95% confidence interval, 1.48-3.64; P = .0003). Rest and exercise wall motion score indexes were higher in the RA group (1.14 6 0.33 and 1.22 6 0.39, respectively, vs 1.06 6 0.18 and 1.10 6 0.24 in controls; P < .005 for each). Logistic regression adjusted for age revealed an increased odds ratio for myocardial ischemia of 1.06 (95% confidence interval, 1.02-1.11; P = .005) per year of RA. Five-year all-cause mortality in subjects with RA with myocardial ischemia on EE was 14.9%, compared with 4.3% in RA subjects without ischemia (P = .028). Conclusion: RA was associated with a 2-fold increased risk for myocardial ischemia on EE; risk increased with the duration of RA. Mortality was increased in patients with RA with ischemia on EE. (J Am Soc Echocardiogr 2009;22:1228-31.) Keywords: Rheumatoid arthritis, Exercise echocardiography, Coronary artery disease, Collagen vascular disease, Stress echocardiography, Ischemia, Autoimmune Rheumatoid arthritis (RA) is a common autoimmune disorder that affects 1% to 2% of the population. 1 Patients with RA are at increased risk for coronary artery disease (CAD) and myocardial infarction. 2,3 The mechanism behind this increased risk is not entirely understood, although inflammation may play a role in the pathogenesis of CAD. Among patients presenting for coronary angiography, patients with RA have an increased incidence of multivessel CAD. 4 Increased cor- onary artery calcification is seen in patients with long-term RA compared with early RA. 5 RA is associated with increased carotid medial thickness and plaque score. 6 There is evidence that the in- creased risk is related to the overall burden of inflammatory disease in RA, established cardiovascular risk factors, and female gender. 3,6-8 Exercise echocardiography (EE) is frequently used for the assess- ment of patients with known or suspected CAD, especially in the presence of repolarization abnormalities on resting electrocardiogra- phy. 9 EE accurately predicts cardiac morbidity, mortality, and out- comes in CAD. 10-13 However, there are no data on the diagnostic accuracy of stress testing, with or without imaging, in patients with RA, nor are there data on the capacity of these modalities to predict outcomes in these patients. We sought to determine whether an increased incidence of CAD exists in patients with RA compared with matched controls, using EE to detect CAD. We also sought to identify clinical characteristics associated with CAD and whether the presence of myocardial ische- mia on EE affected survival in patients with RA. METHODS Patients This retrospective case-control study was approved by the institu- tional review board; all participants agreed that their records could be accessed for research. From 1990 to 2007,17,152 patients were seen at the Mayo Clinic with the diagnosis of RA. Of these, 909 patients underwent stress echocardiography. Selecting only those who underwent EE, 296 patients were identified. Medical records were reviewed to identify patients in whom the diagnosis of RA was confirmed by a rheumatologist. The diagnosis was confirmed in 159 patients; these constituted the RA group. The time from RA diagnosis to EE was recorded. To facilitate data collection, a 1:3 matched case-control study was planned rather than attempting to include the entire population of >70,000 patients who underwent stress echocardiography during this time period. Thus, an attempt was made to find 3 control patients without RA per patient with RA who underwent EE for each patient in the RA group while From the Department of Medicine (M.K.S.), the Division of Cardiovascular Diseases (C.A.J., P.A.P.), the Division of Rheumatology (K.J.W.), and the Division of Biomedical Statistics and Informatics (S.S.C.), Mayo Clinic, Rochester, Minnesota. Reprint requests: Patricia A. Pellikka, MD, Mayo Clinic, Division of Cardiovascular Diseases, 200 First Street SW, Rochester, MN 55905 (E-mail: pellikka.patricia@ mayo.edu). 0894-7317/$36.00 Copyright 2009 by the American Society of Echocardiography. doi:10.1016/j.echo.2009.07.018 1228