coronary heart disease equivalent and an indication for secondary prevention targets even in the absence of clinical cardiovascular disease, it is attractive to consider application of secondary prevention guidelines to patients with RA. From a practical standpoint, a lower target for low-density lipoprotein cholesterol and aspirin therapy would be the main differences in strategy. Secondary prevention measures should certainly be applied in the setting of established cardiovascular disease. Data are lacking to support widespread screening of RA patients with imaging studies such as carotid ultrasonography or computed tomography to detect coronary calcium. Because a negative screening study does not preclude development of atherosclerosis in the short-term future and because both cardiovascular disease prevention efforts and control of disease activity should be aggressive, the presence or absence of subclinical atherosclerosis would arguably not alter overall management. It has been suggested that anti-TNF therapy be temporarily suspended in the perioperative period in patients undergoing major orthopedic surgery to limit increased risk of infection, 22 and similar considerations are likely to apply to cardiac surgery.