Cardiology · Medical Literature
Cardiac Rehabilitation for Cardiovascular Risk Modification in Patients With Rheumatoid Arthritis and Hypertension: A Randomized Controlled Trial.
Abstract
Patients with rheumatoid arthritis (RA) have an increased risk of cardiovascular disease, particularly when hypertension coexists. However, evidence regarding the role of cardiac rehabilitation (CR) in this high-risk population remains limited. In this randomized controlled trial, the effects of a structured CR program on estimated cardiovascular risk, ambulatory blood pressure, and cardiorespiratory fitness were evaluated in patients with RA and hypertension. In this single-center randomized controlled trial, 50 patients with RA and hypertension were randomly assigned (1:1) to a 6-week supervised CR program or usual care. The intervention included supervised aerobic, resistance, and flexibility training together with weekly educational sessions. Outcomes were assessed at baseline and at 6, 12, and 24 weeks by blinded evaluators. The primary outcome was estimated 10-year cardiovascular risk assessed using the Framingham Risk Score (FRS), with QRISK3 analyzed as a supportive risk measure. Secondary outcomes included 24-h ambulatory systolic blood pressure measured by ambulatory blood pressure monitoring (ABPM), cardiorespiratory fitness assessed by treadmill cardiopulmonary exercise testing (VO2max), and rheumatoid arthritis disease activity (DAS28-CRP). Longitudinal changes were analyzed using linear mixed-effects models according to the intention-to-treat principle. Linear mixed-effects modeling demonstrated a significant group × time interaction for FRS (p < 0.001). At Week 24, the between-group difference in FRS was -5.02 points (95% CI -8.60 to -1.44; p = 0.007). QRISK3 showed a similar directional reduction but did not reach statistical significance at Week 24 (-5.77 points; 95% CI -12.54 to 1.01; p = 0.094). Significant group × time interactions were also observed for 24-h ambulatory systolic blood pressure (p < 0.001) and VO2max (p < 0.001). At Week 24, the between-group difference was -9.70 mmHg for ambulatory systolic blood pressure and + 4.90 mL·kg-1·min-1 for VO2max. Disease activity remained within the remission range throughout follow-up. In selected patients with clinically stable rheumatoid arthritis and coexisting hypertension who were receiving stable pharmacologic therapy and were able to participate in supervised exercise, a structured cardiac rehabilitation program was associated with improvements in estimated cardiovascular risk profiles, ambulatory systolic blood pressure, and cardiorespiratory fitness without worsening disease activity. These findings support further evaluation of cardiac rehabilitation as an adjunctive strategy for cardiovascular risk management in a selected cardiometabolically high-risk rheumatoid arthritis population with hypertension. The trial was registered at ClinicalTrials.gov Identifier: NCT06295848.
Clinical relevance
Patients with rheumatoid arthritis (RA) carry a substantially elevated cardiovascular disease burden, which is further compounded by comorbid hypertension; yet structured cardioprotective interventions in this dual-risk population are poorly studied. This RCT addresses a critical evidence gap by evaluating cardiac rehabilitation (CR) as an adjunctive, non-pharmacologic strategy specifically in RA patients with hypertension on stable disease-modifying and antihypertensive therapy. Given the residual cardiovascular risk that persists despite optimal pharmacotherapy in RA, cardiologists and rheumatologists co-managing these patients need actionable data on exercise-based risk reduction.
Key findings
1. Framingham Risk Score (FRS) — Primary Outcome: A significant group × time interaction was observed (p < 0.001); at Week 24, the CR group demonstrated a between-group reduction of −5.02 FRS points (95% CI −8.60 to −1.44; p = 0.007), representing a clinically meaningful decrease in estimated 10-year cardiovascular risk. 2. QRISK3 — Supportive Risk Measure: A directionally consistent reduction of −5.77 points was observed at Week 24 (95% CI −12.54 to 1.01; p = 0.094), which did not achieve statistical significance, likely reflecting limited power given the n = 50 sample size. 3. 24-Hour Ambulatory Systolic Blood Pressure (ABPM): A significant group × time interaction was demonstrated (p < 0.001), with a between-group difference of −9.70 mmHg at Week 24 — a magnitude associated with meaningful reduction in major adverse cardiovascular event risk in hypertension trials. 4. Cardiorespiratory Fitness (VO2max): A significant group × time interaction was observed (p < 0.001), with a between-group improvement of +4.90 mL·kg⁻¹·min⁻¹ at Week 24 — a clinically relevant gain given that each 1 MET improvement in fitness correlates with reduced all-cause and cardiovascular mortality. 5. RA Disease Activity (DAS28-CRP): Disease activity remained within the remission range throughout the 24-week follow-up in both groups, indicating that a 6-week supervised CR program did not exacerbate underlying inflammatory disease. 6. Study Design & Follow-up: This was a single-center, 1:1 randomized controlled trial (n = 50) with a 6-week supervised intervention (aerobic, resistance, and flexibility training plus weekly education) and blinded outcome assessment at baseline and Weeks 6, 12, and 24, analyzed by intention-to-treat using linear mixed-effects models.
Practice implications
Cardiologists and rheumatologists should consider referring clinically stable RA patients with coexisting hypertension who are on optimized pharmacotherapy to a structured, supervised cardiac rehabilitation program, as a 6-week intervention was associated with a ~5-point reduction in 10-year FRS and a ~10 mmHg reduction in 24-hour ambulatory systolic BP without disease flare. Patient selection should prioritize those in RA remission or low disease activity on stable DMARD and antihypertensive regimens, and pre-participation cardiopulmonary exercise testing (VO2max) is advisable to guide exercise prescription and establish a safety baseline. These findings, while hypothesis-generating given the modest sample size and single-center design, support integrating CR as a guideline-consistent adjunctive strategy in the multidisciplinary cardiovascular risk management of this cardiometabolically high-risk population, pending confirmation in larger multicenter trials.