Hypertension in autoimmune rheumatic diseases: progress made, gaps remain

COMMENTARY

Providers working in rheumatology settings are well aware that cardiovascular risk assessment is frequently underemphasized in patients with autoimmune rheumatic diseases (ARD). In this context, Gkaliagkousi et al.[1] provide an important contribution by analyzing and summarizing current evidence in a position paper from the European Society of Hypertension (ESH) entitled “Hypertension in Autoimmune Rheumatic Diseases: A Position Paper from the ESH Working Group on Small Arteries”. The paper focuses on hypertension assessment and cardiovascular disease (CVD) risk evaluation in rheumatology patients. Although frequently overlooked in clinical practice, this topic is critical for improving disease management, quality of life, and survival.

The timely article offers a comprehensive epidemiological overview, highlighting the increased prevalence of hypertension and major cardiovascular events among individuals with ARD, particularly rheumatoid arthritis, which remains the most extensively studied condition in this group. The authors further discuss how chronic inflammation contributes to pathophysiological alterations affecting the heart, kidneys, sympathetic nervous system, and vasculature. In addition, they address the high burden of traditional and nontraditional risk factors in these patients, including obesity, physical inactivity, chronic pain, and psychological comorbidities [1].

A notable strength of this work is the structured, stepwise approach proposed to optimize CVD risk estimation in patients with ARD. In agreement with the authors, we suggest that these concepts should be incorporated into routine rheumatology practice. Specifically, the authors emphasize key elements, including early identification of cardiovascular risk, periodic reassessment in selected cases, and individualized risk stratification based on patient-specific factors, disease duration, and pharmacological treatment. They also recommend the use of the SCORE2 (Systematic Coronary Risk Evaluation-2) algorithm, an updated version of the original SCORE model, which estimates 10-year fatal and nonfatal CVD risk in individuals aged 40–69 years in Europe. This tool incorporates traditional cardiovascular risk factors, including sex, age, smoking status, systolic blood pressure, and non-HDL cholesterol [2]. However, it does not account for disease-specific risk factors, which remain an important limitation. To address this gap, the authors propose reclassification strategies for patients with moderate-to-high CVD risk based on their underlying condition. Regardless, these steps represent a pragmatic and clinically applicable framework for improving risk estimation.

An additional aspect requiring careful consideration in ARD patients is the complexity of pharmacotherapy, which includes immunobiological, chemotherapeutic, immunosuppressant, and anti-inflammatory steroids and nonsteroids. Although immunobiological agents are generally associated with fewer adverse effects and may improve endothelial dysfunction in rheumatoid arthritis (RA) [3], a substantial proportion of patients exhibit inadequate response or limited access due to cost. Conventional therapies, including methotrexate and hydroxychloroquine, have been associated with cardiotoxicity and oxidative stress [4,5], although some evidence suggests potential protective effects against hypertension [6,7]. These findings underscore the importance of individualized therapeutic assessment.

Furthermore, the chronic use of nonsteroidal anti-inflammatory drugs and corticosteroids has been consistently associated with elevated blood pressure (hypertension) in patients with rheumatoid arthritis and systemic lupus erythematosus. These effects are likely mediated by the kidneys’ increased retention of sodium and water, but also involve additional mechanisms, such as endothelial dysfunction and activation of pro-atherogenic pathways [6,8]. Therefore, these pharmacological factors should be systematically integrated into CVD risk evaluation, particularly in the context of hypertension development.

Beyond pharmacological factors, pain and reduced joint mobility represent additional contributors to cardiovascular risk in patients with ARD. Chronic pain is closely associated with psychological distress and may progress to depression [9]. Simultaneously, pain-related functional limitations promote physical inactivity, reinforcing a sedentary lifestyle and further exacerbating cardiovascular risk, including stroke [10]. Accordingly, rheumatic diseases such as RA and systemic lupus erythematosus (SLE) have been identified as independent risk factors for stroke. Notably, even after adjustment for confounders, RA remained associated with an increased risk of ischemic stroke [10]. Furthermore, patients with RA and comorbid depression exhibit the highest risk of stroke [11]. Individuals with RA alone or depression alone still demonstrate an elevated risk of stroke, by 43% and 57%, respectively, compared with those without either condition [11]. Further analyses indicate that RA patients who are male, older, develop depression, or have comorbidities such as hypertension, diabetes, or heart disease are at particularly increased risk [11]. Importantly, both RA and SLE disproportionately affect women, who represent the majority of diagnosed cases [12,13]. This sex bias is particularly relevant given that women with autoimmune diseases may exhibit unique cardiovascular risk profiles, including differences in immune responses, hormonal influences, and vascular function. Moreover, emerging evidence suggests that women with RA or SLE may experience an under-recognition of cardiovascular risk, potentially contributing to adverse outcomes such as stroke. Taken together, these findings highlight that mental health, sex-specific factors, and functional status assessments should be considered integral components of comprehensive cardiovascular risk management in this population.

Given the evidence indicating a higher risk of hypertension in ARD, as well as the prevalence of this patient population, it is reasonable to advocate for greater attention to this group in high blood pressure guidelines from scientific societies, including the American Heart Association, European Society of Hypertension and International Society of Hypertension. Although current guidelines incorporate global cardiovascular risk stratification, they provide limited disease-specific considerations for patients with chronic inflammatory conditions such as RA or SLE. These patients may require more stringent blood pressure control; however, achieving optimal control is often more challenging due to persistent inflammation, comorbidities, and treatment-related effects. While existing treatment models are largely based on overall cardiovascular risk assessment, they may benefit from further refinement to better capture ARD-specific mechanisms and disease burden. ARD-related pathways contribute to both elevated blood pressure and broader cardiovascular complications, reinforcing the need for clinicians to integrate these factors into clinical decision-making. Finally, multidisciplinary collaboration among specialists in hypertension, rheumatology, and immunology will be essential to advance the understanding and management of these complex and interconnected processes.