Rheumatoid arthritis, lupus, psoriasis and other autoimmune diseases raise the risk of heart attack and stroke. The increase is separate from the usual causes such as cholesterol and blood pressure, and it tends to show up at younger ages than people expect.
Standard heart risk calculators have no input for autoimmune disease, so the number they produce can be too low. If you have one of these conditions, the estimate deserves a second look and the ordinary risk factors deserve closer attention.
Key takeaways
- Across 19 autoimmune diseases, a large UK study found cardiovascular disease was roughly one and a half times as common as in matched people without them.
- The relative increase is greatest in younger adults and grows with each additional autoimmune condition.
- General risk calculators mostly underestimate risk in people with rheumatic disease, and attempts to adjust them have not worked well.
- US cholesterol guidance has treated chronic inflammatory conditions as factors that push a borderline estimate upward.
How large is the added risk?
The broadest evidence is a 2022 study in The Lancet that drew on the health records of 22 million people in the UK. It identified 446,449 people newly diagnosed with any of 19 autoimmune diseases and compared them with more than 2.1 million matched people without one.
Over a median of 6.2 years, cardiovascular disease developed at a rate 56% higher in the autoimmune group.1 The risk rose with the number of conditions: 41% higher with one autoimmune disease, more than two and a half times as high with two, and nearly four times as high with three or more.
Age mattered too. Among people younger than 45, cardiovascular disease was more than twice as common in those with an autoimmune disease, while at 75 and older the difference narrowed to 30%.1 Heart disease is still less common in younger adults overall. The point is that an autoimmune diagnosis removes some of the protection that youth normally provides.
Rheumatoid arthritis, lupus and psoriasis
These three conditions have been studied the most.
Rheumatoid arthritis. A meta-analysis of 14 studies covering 41,490 patients found a 48% higher risk of new cardiovascular disease in people with rheumatoid arthritis than in the general population, including a 68% higher risk of heart attack.2
Lupus. In the UK study, systemic lupus erythematosus carried one of the highest risks of any condition examined, at nearly three times the rate of cardiovascular disease seen in matched controls.1 Systemic sclerosis, Addison's disease and type 1 diabetes were the others at the top of the list.
Psoriasis. Risk tracks with severity. In a meta-analysis of nine studies, mild psoriasis was associated with a 29% higher risk of heart attack, and severe psoriasis with a 70% higher risk of heart attack and a 39% higher risk of cardiovascular death.3 The authors cautioned that the studies adjusted for other risk factors to different degrees.
Why inflammation matters
Atherosclerosis is partly an inflammatory process, and autoimmune diseases keep the immune system active for years. That is the leading explanation for the added risk. We cover the biology in our guide to inflammation and heart disease, so it is not repeated here.
Treatment plays a part as well. European rheumatology recommendations advise keeping disease activity under control and keeping steroid doses as low as possible in lupus and vasculitis, as part of managing cardiovascular risk.4 Those are decisions for your rheumatologist. Do not start, stop or change a medication without your prescriber.
Why calculators underestimate
Risk calculators such as PREVENT are built from age, blood pressure, cholesterol, diabetes, smoking and kidney function. Autoimmune disease is not one of the inputs, so two people with identical numbers get the same estimate even if one has had rheumatoid arthritis for 15 years.
A systematic review of studies that tested these tools in people with rheumatic diseases concluded that general risk algorithms mostly underestimate, and at times overestimate, cardiovascular risk in these patients.5 Attempts to fix the problem with multipliers or disease-specific variables largely failed to improve the estimates in rheumatoid arthritis and lupus.
For lupus and several other rheumatic diseases, European recommendations still advise using the general tools, because no validated disease-specific tool exists.4 The estimate is then interpreted with the diagnosis in mind.
US guidance has handled this through the idea of risk enhancers. The 2018 US cholesterol guideline named chronic inflammatory disorders, with rheumatoid arthritis and psoriasis as examples, among the risk-enhancing factors that favor treatment when a calculated risk is intermediate.6
What gets checked
- The standard risk factors. Blood pressure, a lipid panel, blood sugar and smoking status matter at least as much as in anyone else.
- A calculated risk estimate. It is read with your diagnosis in mind, because it may run low.
- Inflammation markers, with care. A raised hs-CRP may reflect the autoimmune disease itself, which makes it harder to read as a heart signal. See our guide to causes of a high hs-CRP.
- Imaging in selected cases. When the estimate is uncertain, a coronary calcium score is one test clinicians use to look for plaque directly.
Your disease history is part of the assessment too: how long you have had the condition, how active it has been and which medications you have taken.
Your next step
If you have an autoimmune disease and no one has reviewed your heart risk, raise it at your next visit and make sure the clinician knows your diagnosis when reading the estimate. Bring your recent blood pressure readings and lipid results.
You can also answer the three quick questions in the screener on the Cardio Res-Q program page. Autoimmune conditions such as arthritis and psoriasis are among the risk factors listed on that page.
Are You a Candidate for Cardio Res-Q?
Three quick questions about the risk factors we screen for. Your answers stay between you and the clinic.
Frequently asked questions
Does treating my autoimmune disease lower my heart risk?
Controlling disease activity is part of what European recommendations advise for managing cardiovascular risk. The same recommendations note that no particular immunosuppressive treatment in lupus has been shown to lower cardiovascular risk. Good disease control and attention to standard risk factors go together, and neither replaces the other.
Which autoimmune diseases carry the highest heart risk?
In the large UK study of 19 conditions, systemic sclerosis, Addison's disease, lupus and type 1 diabetes had the highest overall cardiovascular risk. Every condition studied showed some increase, and having more than one raised the risk further.
My calculated heart risk is low. Can I rely on it?
Treat it as a starting point. The calculators do not account for autoimmune disease, and studies show they mostly underestimate risk in people with rheumatic conditions. Ask your clinician how your diagnosis changes the reading of your number.
Related reading
This article is for general education and is not medical advice. Decisions about testing and medication should be made with your clinician. If you have chest pain or other symptoms of a heart attack, call 911.
