Knowledge of features of inflammatory back pain in primary care in the West Midlands: a cross-sectional survey in the United Kingdom.

KEY MESSAGES: There is a relative lack of confidence among GPs in the assessment and management of IBP vs. mechanical back pain. A simple screening tool for SpA, applicable in primary care urgently needs to be developed. It is reasonable for patients with symptoms suggestive of inflammatory back pain to be referred to secondary care without further investigations. The objective of this study was to assess current practice of our local general practitioners (GPs) in using clinical features, as well as radiological and laboratory investigations to assess patients with IBP. An online, observational questionnaire-based survey was done in 10 West Midlands CCGs including disparate geographical and socioeconomic areas. The survey consisted of 23 questions based on Calin, Berlin and ESSG Criteria for spondyloarthropathies. GPs were asked to rate the importance of a range of symptoms as indications of IBP IBP (10 point scale, range 1-10), and what their views were on which were the most important treatments for patients with suspected inflammatory back pain(4 point scale, range 1-4). The 4 most important symptoms for predicting inflammatory back pain according to our local cohort of GPs were 'morning stiffness' 'sleep disturbances caused by back pain' 'insidious onset' and 'age of onset' < 45. Among the treatment options, NSAIDs were ranked as the most important treatment option for IBP. DMARDS were rated as the next most important treatment option, ahead of physiotherapy and anti-TNF therapy. This study has highlighted relative lack of confidence among GPs in the assessment of IBP. Whether this reflects a need for education or poor performance of these questions in primary care populations requires further study.

Hypertension in rheumatoid arthritis.

RA associates with an increased burden of cardiovascular disease, which is at least partially attributed to classical risk factors such as hypertension (HT) and dyslipidaemia. HT is highly prevalent, and seems to be under-diagnosed and under-treated among patients with RA. In this review, we discuss the mechanisms that may lead to increased blood pressure in such patients, paying particular attention to commonly used drugs for the treatment of RA. We also suggest screening strategies and management algorithms for HT, specific to the RA population, although it is clear that these need to be formally assessed in prospective randomized controlled trials designed specifically for the purpose, which, unfortunately, are currently lacking.

Excess recurrent cardiac events in rheumatoid arthritis patients with acute coronary syndrome.

BACKGROUND: Cardiovascular mortality is increased in rheumatoid arthritis. Possible reasons include an increased incidence of ischaemic heart disease or worse outcome after acute coronary syndrome (ACS). OBJECTIVES: To assess the outcome of ACS in rheumatoid arthritis compared with case matched controls in the context of underlying cardiac risk factors, clinical presentation, and subsequent management. METHODS: 40 patients with rheumatoid arthritis and ACS identified from coronary care admission registers between 1990 and 2000 were case matched as closely as possible for age, sex, classical cardiovascular risk factors, type and severity of ACS, and admission date (+/-3 months) with 40 controls. A standardised proforma was used for detailed case note review. RESULTS: Age, sex, other cardiovascular risk factors, and type and severity of presenting ACS were not significantly different between cases and controls. Recurrent cardiac events were commoner in rheumatoid arthritis (23/40, 57.5%) than controls (12/40, 30%) (p = 0.013); there were 16/40 deaths in rheumatoid arthritis (40%) v 6/40 (15%) in controls (p = 0.012). Recurrent events occurred earlier in rheumatoid arthritis (log rank survival, p = 0.05). Presentation with chest pain occurred in all controls compared with 33/40 rheumatoid patients (82%) (p = 0.006); collapse occurred in one control (2.5%) v 7/40 rheumatoid patients (17.5%) (p = 0.025). Treatment during the ACS was not significantly different in the two groups. CONCLUSIONS: Recurrent ischaemic events and death occur more often after ACS in rheumatoid arthritis. Atypical presentation is commoner in rheumatoid arthritis. There is an urgent need to develop identification and intervention strategies for ACS specific to this high risk group.

Self-referral of symptoms (SOS) follow-up system of appointments for patients with uncertain diagnoses in rheumatology out-patients.

OBJECTIVE: Clinical features in rheumatological conditions often fluctuate with time and this may cause difficulty when evaluating patients whose symptoms or signs do not coincide with their initial rheumatology visit. The aim of this study was to evaluate the outcome of a follow-up system whereby patients with uncertain rheumatological diagnoses at their initial assessment are given easy and rapid access to a rheumatology review. METHOD: We studied the outcome of SOS (self-referral of symptoms) appointments offered to patients over a 44-month period in one consultant's clinic at the Staffordshire Rheumatology Centre. The reattendance rates and diagnoses at the initial and subsequent visits were evaluated over a mean period of 26.3 months (range 7-64 months). RESULTS: Thirty-seven patients (23 males, 14 females) were offered SOS appointments during the period studied. At the initial assessment, a provisional diagnosis was recorded for 29 patients (78.4%), whereas the diagnosis was unclear for the other eight patients. At the end of the study period, 10 patients (27%) had requested specialist review via the SOS system after a mean period of 6.8 months (1-19 months). The diagnosis remained unchanged in 8 of the 10 reattenders, whereas the diagnosis was revised in two patients. None of these patients, however, developed an inflammatory arthritis. CONCLUSION: We suggest that an SOS system of appointments may be a feasible and practical method to follow up patients who have uncertain rheumatological diagnoses at their initial visit. This follow-up system may not easily fit into the current out-patient reforms being implemented in the National Health Service, yet this form of specialist follow-up seems clinically essential for some forms of disease management. The requirements necessary to operate such a system as well as the envisaged pros and cons for the patient and for the rheumatologist are discussed.

Risk assessment for coronary heart disease in rheumatoid arthritis and osteoarthritis.

BACKGROUND: The risk of coronary heart disease (CHD) is increased in rheumatoid arthritis (RA). The reasons for this remain unknown, but traditional risk factors for CHD identified in the general population may be important contributors. OBJECTIVE: To assess comparatively the prevalence of traditional CHD risk factors and the absolute 10-year CHD risk in patients with RA or osteoarthritis (OA) without known cardiovascular co-morbidity. METHODS: Consecutive Caucasian hospital outpatients with RA (n = 150) or OA (n = 100) aged 40-75 years were assessed for known cardiovascular co-morbidity, age, sex, smoking status, presence of diabetes mellitus (DM), height, weight, systolic blood pressure (BP), total cholesterol (TC) and HDL cholesterol. Absolute 10-year CHD risk for each individual was calculated using the Joint British Societies CHD risk calculator. RESULTS: Prevalence and distribution of known cardiovascular co-morbid conditions were similar in RA (56/150, 37%) and OA (34/100, 34%). The resulting subgroups of patients without known co-morbidity (RA: n = 94; OA: n = 66) were not significantly different for age, sex, DM, smoking, systolic BP or TC: HDL cholesterol ratio. There was no significant difference in the absolute 10-year CHD risk between RA and OA (15.6+/-11.0 versus 14.8+/-9.3, p = 0.63). However, a significant proportion of patients without known cardiovascular disease in both the RA and OA subgroups had a 10-year CHD risk above the 15% or 30% risk levels, indicating the need for possible or definite intervention respectively. Over 80% of RA patients had at least 1 CHD risk factor that could be modified. CONCLUSION: Absolute 10-year CHD risk was not different between RA and OA patients in this study. Substantial numbers of RA and OA patients have potentially modifiable CHD risk factors present. We suggest that CHD risk should be assessed and modifiable risk factors addressed in the routine rheumatology clinic setting.