How safe for the heart is hydroxychloroquine use in RA patients?

The risks of sudden cardiac arrest or ventricular arrythmia (SCA/VA) and major adverse cardiovascular event (MACE) are comparable between methotrexate (MTX) and hydroxychloroquine (HCQ) in older patients with rheumatoid arthritis (RA), reports a study.

However, HCQ users with a history of heart failure (HF) are at higher risk of MACE, cardiovascular mortality, all-cause mortality, and myocardial infarction (MI). Additionally, HCQ initiators have an increased hospitalized HF risk regardless of an HF history.

The investigators used Medicare data (2008‒2016) and identified 54,462 propensity score-matched patients with RA, aged ≥65 years, who initiated HCQ or MTX. They assessed SCA/VA and MACE as primary outcomes, as well as cardiovascular mortality, all-cause mortality, MI, stroke, and hospitalized HF as secondary ones. Treatment effect modification by HF history was also examined.

HCQ use did not significantly increase the risk of SCA/VA (hazard ratio, 1.03, 95 percent confidence interval [CI], 0.79‒1.35) or MACE (HR, 1.07, 95 percent CI, 0.97‒1.18) relative to MTX.

Among patients with HF history, HCQ initiators demonstrated a higher risk of MACE (HR, 1.30, 95 percent CI, 1.08‒1.56), cardiovascular mortality (HR, 1.34, 95 percent CI, 1.06‒1.70), all-cause mortality (HR, 1.22, 95 percent CI, 1.04‒1.43), MI (HR, 1.74, 95 percent CI, 1.25‒2.42), and hospitalized HF (HR, 1.29, 95 percent CI, 1.07‒1.54) than MTX initiators.

Of note, cardiovascular risks were similar in patients without HF history, except for a higher risk of hospitalized HF (HR, 1.57, 95 percent CI, 1.30‒1.90) among HCQ users.

“HCQ is often used as a first-line treatment of RA despite limited evidence on its cardiovascular risk,” the investigators said.