Study: Chest X-ray abnormalities of RA patients worth reporting

Radiologists interpreting the chest radiographs of rheumatoid arthritis (RA) patients should report abnormalities and incidental findings, as they may be unknown to the patient’s physician and could impact clinical management. according to an Irish study published in the Aug. 8, 2019, online edition of Clinical Rheumatology.¹

Physicians at St. James’s Hospital and Trinity College, both in Dublin, studied the unreported abnormalities of  chest radiographs of 163 patients treated at St. James Hospital. The patients were part of a total cohort of 198 consecutive patients receiving treatment at St. James’s Hospital. The group included 143 women and 53 men, ranging in age from 18 to 90 years, with a mean age of 62. The patients represented a general RA population, and had the disease for a mean duration of 16 years.

The chest X-rays had been ordered as screening investigations for 88 patients and to investigate respiratory symptoms for the remainder. Seventy-nine percent of the exams were abnormal; abnormalities were primarily bone (60%), pulmonary (44%), and signs of old cases of tuberculosis (21%). Lung hyperinflation, interstitial changes, pneumonia, pneumothorax, and cancerous/benign lung nodules were also identified.

However, 154 abnormalities in 108 patients were not included in the radiology reports. The highest percentages of 120 of these abnormalities not reported included:

• 90% - Degenerative spine disease
• 88% - Aortic calcification
• 86% - Shoulder abnormalities
• 67% - Rib fractures
• 62% - Scoliosis
• 59% - Old tuberculosis.

Lead author and St. James rheumatologist Michael R. Goggins, MD, explained that evidence of lung disease, including latent tuberculosis, is “of great relevance in the consideration of immunosuppressive treatment, particularly with biologic agents.” Dr. Goggins and his co-authors wrote that “early identification of chronic obstructive pulmonary disease is essential to symptomatic relief and prevention of infective exacerbations,” yet 11 of 24 cases of pulmonary hyperinflation were not reported.

Similarly, while bony abnormalities are often considered unimportant incidental findings, alerting physicians to their presence, especially in patients with arthritis, who may underreport their symptoms, may facilitate treatment through physiotherapy, occupational therapy, or surgery. Vertebral fractures should trigger osteoporosis risk assessments and relevant treatment.

The Arthritis Foundation reports that individuals with RA are at highest risk of dying from cardiovascular disease.¹ The organization cites several studies reporting that over 50% of premature deaths in RA are attributable to cardiovascular disease.² A 2018 study representing 16 organizations from 11 nations reported that “in a large, international cohort of patients with RA, 30% of cardiovascular disease events were attributable to RA characteristics.”³  Because cardiovascular disease is the most common cause of death in patients with RA, the authors stress the importance of identifying “such abnormalities and perform[ing] further risk assessments to neutralize the morbidity and mortality associated with atherosclerosis.” Yet only 24 of 61 cardiac abnormalities identified in the study were initially reported.

Co-author Richard Conway, MD, PhD, a rheumatologist and epidemiologist at the Centre for Arthritis and Rheumatic Diseases at St. Vincent’s University Hospital in Dublin, said, “We recommend that rheumatologists review the images of radiology investigations they request, either independently or with a radiologist, and not merely the written reports of these investigations. We believe time spent in image review will be very beneficial to all.”

REFERENCES

1. Goggins MR, Conway R, Durcan LJ. High prevalence of abnormalities on chest radiography in rheumatoid arthritis. Clin Rheumatol. Published online August 8, 2019. doi: 10.1007/s10067-019-04717-9
2. Arthritis Foundation. “Arthritis and Heart Disease: Why people with arthritis are at greater risk for heart disease.” Accessed from https://www.arthritis.org/living-with-arthritis/comorbidities/heart-disease on August 14, 2019.
3. Crowson CS, Rollefstad S, Ikdahl E, et al. Impact of risk factors associated with cardiovascular outcomes in patients with rheumatoid arthritis. Ann Rheum Disease. 2019;77(1):48-54.