Patients with rheumatoid arthritis (RA) are at increased risk of mortality compared with the general population. Evidence suggests that this increased mortality can largely be attributed to increased cardiovascular (CV) death. In a retrospective study of an inception cohort of RA patients in Rochester, MN, we found that patients with RA were at increased risk of CV death, ischemic heart disease, and heart failure compared with age- and sex-matched community controls. In addition, when we examined coronary artery tissue from autopsied RA patients, we observed increased evidence of inflammation and an increased proportion of unstable plaques. We also investigated the contribution of traditional and RA-specific risk factors to this increased risk of CV morbidity and mortality. Although traditional CV disease risk factors were found to contribute to the increased risk of mortality in RA patients, they did not fully explain the increased CV mortality observed in RA. Instead, increased inflammation associated with RA appears to contribute substantially to the increased CV mortality. Together with other studies that have demonstrated similar associations between RA and CV mortality, these data suggest that more aggressive management of inflammation in RA may lead to significant improvements in outcomes for patients with RA.