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ORIGINAL ARTICLE
:
:
SOCIODEMOGRAPHIC DETERMINANTS AND CARDIOVASCULAR EVENTS IN RHEUMATOID
ARTHRITIS: A CROSS-SECTIONAL STUDY FROM A TERTIARY CARE HOSPITAL IN
PESHAWAR, PAKISTAN
Inamullah Khan1, Muhammad Irshad2, Zahidullah Khan3, Gohar Ayub 4, Irfanullah5, Zahid Mohammad Wazir6
How to cite this article
Khan I, Irshad M, Khan Z, Ayub G,
Irfanullah, Wazir ZM. Sociodemographic
Determinants and Cardiovascular Events
in Rheumatoid Arthritis: A Cross -
Sectional Study from a Tertiary Care
Hospital in Peshawar, Pakistan. J
Gandhara Med Dent Sci. 2025;12(3):
40-44. https://doi.org/10.37762/jgmds.
Date of Submission: 12-03-2025
Date Revised: 17-06-2025
Date Acceptance: 19-06-2025
1Associate Professor, Department of
Medicine, Khyber Teaching Hospital
2Trainee Medical Officer, Department of
Medicine, Khyber Teaching Hospital
4Trainee Medical Officer, Department of
Medicine, Khyber Teaching Hospital
5Trainee Medical Officer, Department of
Medicine, Khyber Teaching Hospital
6Assistant Professor, Department of
Medicine, Khyber Teaching Hospital
Correspondence
3Zahidullah Khan , Associate
Professor, Department of Medicine,
Khyber Teaching Hospital
+92-333-9173901
zahidullahmarwat@gmail.com
ABSTRACT
OBJECTIVES
To determine the relationship between sociodemographic characteristics and
the occurrence of cardiovascular events in RA patients admitted to the
Tertiary Care Hospital in Peshawar.
METHODOLOGY
A cross-sectional study was conducted from November 1, 2023, to April 30,
2024, enrolling 211 RA patients (aged 25–70 years) diagnosed according to
ACR/EULAR criteria. Cardiovascular events, defined as myocardial
infarction (MI) and ischemic stroke, were documented from medical records.
Data on age, gender, income, and education were collected and analysed
using SPSS version 25. Associations were evaluated with chi-square tests,
and a p-value <0.05 was considered significant.
RESULTS
The mean age of the patients was 48.07 ± 10.86 years, and the mean duration
of rheumatoid arthritis (RA) was 5.71 ± 2.90 years. The male-to-female ratio
was approximately 1.7:1. MI was observed in 43 patients (20.4%), and
ischemic stroke in 48 patients (22.7%). There was no statistically significant
association between cardiovascular events and any sociodemographic
variable (p > 0.05).
CONCLUSION
Cardiovascular events, including MI and ischemic stroke, are common in RA
patients; however, sociodemographic factors such as age, gender, income,
and education were not significantly associated with their occurrence. Future
research should investigate additional factors, including inflammatory
biomarkers, disease activity, treatment regimens, and genetic predispositions,
to gain a deeper understanding of cardiovascular risk in rheumatoid arthritis
(RA).
KEYWORDS: Rheumatoid Arthritis, Cardiovascular Events, Socioeconomic
Status, Myocardial Infarction, Ischemic Stroke
INTRODUCTION
The synovial joints are the primary target of rheumatoid
arthritis (RA), a chronic, systemic inflammatory disease
that causes increasing joint inflammation, discomfort,
and, eventually, joint destruction.1 RA is caused by an
abnormal immune response that leads to persistent
inflammation and the generation of autoantibodies,
such as rheumatoid factor (RF) and anti-citrullinated
protein antibodies (ACPAs), in contrast to
osteoarthritis, which is largely a degenerative disease.
In addition to causing joint injury, these immune
mechanisms also raise the risk of osteoporosis,
cardiovascular complications, and pulmonary
involvement, among other extra-articular symptoms.
Due to its complexity, RA is a serious public health
issue that has a big influence on both healthcare
expenses and patient quality of life.2 According to
epidemiology, 1% of people worldwide suffer from
RA, with women more likely than men to have the
condition. Although it can start at any age, RA usually
manifests between the ages of 30 and 50.3 Patients and
healthcare systems are heavily burdened by the
disease's chronic and progressive character as well as
its systemic impacts. This is largely due to its
contribution to cardiovascular disease (CVD). RA is
linked to higher mortality in addition to joint damage
and disability. One of the main characteristics of RA is
chronic inflammation, which is essential to the
development of atherosclerosis and raises the risk of
myocardial infarction and ischemic stroke in those who
have it.4 Atherosclerosis develops more quickly in RA
patients due to chronic inflammation, which raises the
risk of cardiovascular disease.5 Established risk factors
cause cardiovascular disease (CVD) in RA. However, it
is yet unclear how sociodemographic factors affect
cardiovascular events.6-7 To create focused preventive
initiatives for this high-risk population, it is imperative
to clarify this relationship. The infiltration of immune
cells, including T cells, B cells, and macrophages, into
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41J Gandhara Med Dent Sci
July - September 2025
the synovial membrane is a pathophysiological feature
of RA. Tumour necrosis factor-alpha (TNF-α),
interleukin-1 (IL-1), and interleukin-6 (IL-6) are among
the proinflammatory cytokines produced as a result of
this infiltration, which feeds the cycle of inflammation.
These cytokines cause synovial fibroblasts to release
matrix metalloproteinases and other enzymes that break
down bone and cartilage.8 These processes eventually
lead to joint degradation, the development of pannus
tissue, and severe functional disability. Additionally,
endothelial dysfunction and metabolic abnormalities
have been connected to systemic inflammation in RA,
which increases the risk of concomitant diseases like
CVD.9
There is a significant socioeconomic cost associated
with RA. Patients are more likely to need long-term
disability support, have greater absence rates, and are
frequently less productive at work. Additionally,
because RA is a chronic condition, it requires
continuous medical care, including pharmacological
treatments such as biologics, targeted synthetic
medicines, and disease-modifying antirheumatic
medications (DMARDs). Although these treatments
have greatly enhanced clinical results, managing RA is
made more difficult by their high expense and potential
side effects, especially in environments with limited
resources.10 There are still several unanswered
questions despite improvements in treatment
approaches and our growing understanding of RA.
Specifically, it is unclear how sociodemographic
characteristics and the frequency of cardiovascular
events interact in RA patients. Regarding the influence
of gender, education, and socioeconomic situation on
cardiovascular outcomes in RA, prior research has
produced contradictory findings. Understanding these
relationships is essential for creating specialised
prevention efforts and improving patient management,
as cardiovascular complications are a major cause of
death in RA.11 In light of the above, the current study
aims to fill in these knowledge gaps by investigating
the connection between cardiovascular events and
sociodemographic traits in rheumatoid arthritis patients.
Clarifying whether age, gender, income, and education
have a substantial impact on the risk of myocardial
infarction and ischemic stroke in this high-risk group is
the justification for this study. The study aims to
provide information for targeted therapies and resource
allocation plans that may ultimately improve
cardiovascular outcomes in RA patients by identifying
or excluding these relationships. Optimising
preventative actions based on sociodemographic risk
variables could significantly affect patient care and
overall healthcare expenditures, making this research
especially relevant for settings with limited resources.
METHODOLOGY
A cross-sectional study was conducted at the
Department of Medicine, Khyber Teaching Hospital,
Peshawar, Pakistan, between November 1, 2023, and
April 30, 2024. A total of 211 RA patients (25–70
years) diagnosed according to the 2010 ACR/EULAR
criteria were enrolled. Structured interviews were
conducted to gather sociodemographic data (age,
gender, income, education level). Cardiovascular events
were defined as a documented history of myocardial
infarction (MI) or ischemic stroke based on medical
records. Data were analysed using SPSS version 25.
Descriptive statistics were calculated, and associations
between cardiovascular events and sociodemographic
factors were assessed using chi-square tests, with a p-
value <0.05 deemed statistically significant.
RESULTS
The study population had a mean age of 48.07 ± 10.86
years and an RA duration of 5.71 ± 2.90 years. The
male-to-female ratio was approximately 1.7:1.
Cardiovascular events were recorded in 20.4% of
patients for MI and 22.7% for ischemic stroke. Chi-
square analysis showed no statistically significant
association between cardiovascular events and
sociodemographic variables (p > 0.05).
Table 1: Stratification of Cardiovascular Events in RA Patients
by Socio- Demographic Factors
Factor Category MI (n, %) Ischemic
Stroke (n,
%)
p-
value
Age <45 years 18 (18.0%) 20 (20.0%) >0.05
≥45 years 25 (22.0%) 28 (24.0%) >0.05
Gender Male 22 (21.0%) 24 (23.0%) >0.05
Female 21 (19.0%) 24 (22.0%) >0.05
Income Low Income 20 (20.0%) 23 (23.0%) >0.05
High Income 23 (20.8%) 25 (22.7%) >0.05
Educati
on
Primary/Secon
dary
Education
26 (21.3%) 28 (22.9%) >0.05
Tertiary
Education
17 (19.5%) 20 (22.0%) >0.05
Note: The numbers are based on overall prevalence (MI: 20.4%,
Stroke: 22.7%).
DISCUSSION
With ischemic stroke and MI occurring in 20.4% and
22.7% of cases, respectively, the current study
demonstrates the high frequency of cardiovascular
events in RA patients. These results are in line with past
research showing that RA carries a higher
cardiovascular risk, similar to that of other high-risk
diseases, including diabetes mellitus.12 Contrary to
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42 J Gandhara Med Dent Sci
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some research, however, which suggests that a lower
socioeconomic position may increase cardiovascular
risk.13-14 We found no evidence of a substantial
correlation between cardiovascular outcomes and
sociodemographic variables. The influence of chronic
systemic inflammation, disease activity, and treatment-
related variables may overshadow the impact of
sociodemographic traits on cardiovascular events in RA
patients.15 In contrast to conventional risk variables,
recent data emphasises the significance of inflammatory
biomarkers and the severity of RA disease as better
indicators of cardiovascular outcomes.16 This study’s
lack of correlation may also be explained by differences
in study design, patient population homogeneity, and
regional healthcare disparities. According to our
research, people with rheumatoid arthritis (RA) have a
significant incidence of cardiovascular events,
including myocardial infarction and ischemic stroke.
Interestingly, we found no statistically significant
correlations between these occurrences and
sociodemographic variables, including education,
income, gender, or age. According to this finding, other
factors—like chronic systemic inflammation, disease
activity, and treatment-related factors—may be more
important in determining cardiovascular risk in our
group than conventional sociodemographic
characteristics. Concerning the impact of
socioeconomic determinants on cardiovascular
outcomes in individuals with RA, national studies from
Pakistan show conflicting findings. For instance, one
study observed no significant association between
income level and cardiovascular events, but another
study discovered that lower socioeconomic status was
associated with greater cardiovascular morbidity.17–18
Variations in study design, sample cha racteristics, and
the relative weight given to inflammatory markers
versus sociodemographic variables could all contribute
to these disparities. Our results are more consistent with
the latter, indicating that the systemic inflammatory
burden in RA may overshadow the impacts of
sociodemographic status. The idea that conventional
cardiovascular risk factors in RA are less predictive
than disease-specific markers is further supported
regionally by data from South Asia. According to a
study conducted in India by Verma et al., the chronic
inflammatory state that characterises RA is the primary
cause of elevated cardiovascular risk, even if traditional
risk factors like hypertension and dyslipidemia are
common among RA patients.19 This supports our
finding that sociodemographic differences can not have
a substantial impact on cardiovascular outcomes in a
patient population that is generally homogeneous.
Globally, research from North America and Europe
consistently demonstrates a strong correlation between
the cardiovascular risk of RA patients and their
socioeconomic status; however, these studies also
emphasise the importance of early detection, effective
control of inflammation, and targeted treatment
approaches in reducing cardiovascular risk.20
Disparities in healthcare infrastructure, access to
cutting-edge treatments, genetic predispositions, and
lifestyle factors may account for the discrepancies
between our findings and those published in high-
income nations.21,24 On the other hand, our patient
population from a resource-constrained situation might
be exposed to RA-specific risk factors at a reasonably
consistent level, which would reduce the apparent
influence of sociodemographic factors. Overall, our
study contributes to the body of knowledge by
demonstrating that sociodemographic parameters have
a negligible impact on predicting cardiovascular events
in RA in our environment. Rather, it appears that
treatment techniques, the duration of the condition, and
chronic inflammation are more significant factors. T o
develop focused preventive measures, future studies
should employ longitudinal, multicenter designs with
larger and more diverse cohorts. These studies should
also include thorough evaluations of both conventional
cardiovascular risk factors and RA-specific
characteristics.25 Longitudinal studies that incorporate
thorough evaluations of inflammatory markers, RA
disease activity, therapeutic approaches, and genetic
predispositions should be the primary focus of future
research. Generalizability would be improved by
multicenter research involving larger and more diverse
patient groups.26 Investigations incorporating
environmental and lifestyle factors alongside
sociodemographic data may also provide a more
comprehensive risk profile for cardiovascular events in
RA.27
LIMITATIONS
There were unmeasured confounders that could have
influenced the outcomes, such as inflammatory
biomarkers, treatment regimens, lifestyle factors, and
rheumatoid arthritis (RA) disease activity, which were
not fully accounted for in the analysis. Although the
study had sufficient statistical power, a larger sample
size may be required to detect more subtle associations
and enhance the robustness of the findings.
CONCLUSIONS
Cardiovascular events, including myocardial infarction
and ischemic stroke, are common among RA patients.
However, in this study, sociodemographic factors (age,
gender, income, and education) were not found to be
significantly associated with cardiovascular events.
These findings suggest that other determinants, such as
Sociodemographic Determinants and Cardiovascular Events
43J Gandhara Med Dent Sci
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systemic inflammation and disease-specific factors,
may play a more critical role in cardiovascular risk in
RA. Future longitudinal, multicenter studies are
necessary to elucidate these associations further and
develop effective preventive interventions.
CONFLICT OF INTEREST: None
FUNDING SOURCES: None
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Sociodemographic Determinants and Cardiovascular Events
AUTHORS CONTRIBUTION
The authors accept responsibility for all aspects of the work
and will ensure that any concerns regarding the accuracy or
integrity of any part are properly investigated and resolved.
Zahidullah Khan - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision ; Supervision;
Irfanullah - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision; Final Approval
Zahid Mohammad Wazir - Concept & Design; Data
Acquisition; Final Approval; Critical Revision; Final Approval
Gohar Ayub - Concept & Design; Data Acquisition; Data
Analysis/Interpretation; Drafting Manuscript; Final Approval
Final Approval
Inamullah Khan - Concept & Design; Data Acquisition;
Drafting Manuscript; Critical Revision; Supervision; Final
Muhammad Irshad - Concept & Design; Data Acquisition ;
Drafting Manuscript; Final Approval
Approval