Beyond the joints, what is the leading cause of excess mortality in rheumatoid arthritis?

Correct answer: A. Cardiovascular disease, particularly myocardial infarction

• A. CORRECT. CARDIOVASCULAR DISEASE accounts for the largest share of excess mortality in rheumatoid arthritis, with roughly a 50% higher risk of myocardial infarction than the general population. The driver is CHRONIC SYSTEMIC INFLAMMATION — persistently elevated cytokines accelerate atherosclerosis independently of the traditional risk factors, and the effect is proportional to disease activity. The parallel with periodontitis and cardiovascular risk is exactly the same mechanism, which is why this appears on a dental examination.
• B. Renal involvement occurs, but more often as a consequence of long-term NSAID use or of secondary amyloidosis than as a leading cause of death.
• C. Hepatic disease is a monitoring concern with methotrexate rather than a feature of the underlying disease.
• D. Interstitial LUNG disease is a recognised extra-articular manifestation and does contribute to mortality, but it does not exceed the cardiovascular burden. COPD is a smoking-related disease, and smoking is a shared risk factor rather than a consequence.

Note: Other extra-articular features worth carrying: rheumatoid nodules, secondary Sjögren syndrome — with the xerostomia and rampant cervical caries that follow — anaemia of chronic disease, scleritis, and Felty syndrome (rheumatoid arthritis with splenomegaly and neutropenia). TMJ involvement affects a large minority and can produce an anterior open bite as the condyles resorb.