The heart in rheumatoid arthritis: Difference between revisions
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==Overview== | ==Overview== | ||
The cardiac complications in [[rheumatoid arthritis]] are usually due to involvement by [[rheumatoid nodule]], [[inflammatory]] mediators and antirheumatic drugs. There is increased risk of [[coronary atherosclerosis]] and thereby increasing the risk of [[heart failure]] and [[atrial fibrillation]]. Other possible complications include [[pericarditis]], [[myocarditis]] and conduction defects. Cardiac disease with [[rheumatoid arthritis]] can be related to [[granulomatous]] proliferation, [[inflammatory]] mediators, and antirheumatic drugs . [[Echocardiography]] is helpful in diagnosing [[pericarditis]], [[ejection fraction]] and [[endocardial]] [[inflammation]]. Other useful tests are [[ECG]], [[Complete blood count|CBC]], [[ESR]], [[CRP]], and troponins. Treatment of underlying cause is important. Treatment of [[pericarditis]] include [[Non-steroidal anti-inflammatory drug|NSAIDs]] and [[glucocorticoids]]. Treatment of [[myocarditis]] is [[methylprednisolone]] pulse therapy. [[Pacemakers and implantable defibrillators (patient information)|Pacemakers]] are used for conduction defects. | |||
== | == Cardiac complications of rheumatoid arthritis == | ||
The cardiac complications in rheumatoid arthritis are due to involvement by rheumatoid | The cardiac complications in rheumatoid arthritis are usually due to involvement by [[rheumatoid nodule]], [[inflammatory]] mediators and antirheumatic drugs. There is increased risk of [[coronary atherosclerosis]] and thereby increasing the risk of [[heart failure]] and [[atrial fibrillation]]. Various cardiac complications include: | ||
'''Coronary artery disease''' | |||
There is increased risk of coronary artery disease in [[rheumatoid arthritis]]. It could be due to [[chronic inflammation]] caused by [[cytokines]], [[lymphocytes]], [[macrophages]], and [[dendritic cells]]. Other factors responsible are [[coagulation]] abnormalities, [[Immune complex|immune complexes]], and [[oxidative stress]].<ref name="pmid11953961">{{cite journal |vauthors=Van Doornum S, McColl G, Wicks IP |title=Accelerated atherosclerosis: an extraarticular feature of rheumatoid arthritis? |journal=Arthritis Rheum. |volume=46 |issue=4 |pages=862–73 |date=April 2002 |pmid=11953961 |doi= |url=}}</ref><ref name="pmid12022343">{{cite journal |vauthors=Wållberg-Jonsson S, Cvetkovic JT, Sundqvist KG, Lefvert AK, Rantapää-Dahlqvist S |title=Activation of the immune system and inflammatory activity in relation to markers of atherothrombotic disease and atherosclerosis in rheumatoid arthritis |journal=J. Rheumatol. |volume=29 |issue=5 |pages=875–82 |date=May 2002 |pmid=12022343 |doi= |url=}}</ref><ref name="pmid10648020">{{cite journal |vauthors=Wållberg-Jonsson S, Cederfelt M, Rantapää Dahlqvist S |title=Hemostatic factors and cardiovascular disease in active rheumatoid arthritis: an 8 year followup study |journal=J. Rheumatol. |volume=27 |issue=1 |pages=71–5 |date=January 2000 |pmid=10648020 |doi= |url=}}</ref> | |||
'''Heart failure''' | |||
The risk of [[heart failure]] is relatively more common in patient with [[coronary artery disease]] in rheumatoid arthritis. This is caused by [[left ventricular dysfunction]], [[inflammatory]] mediators, and antirheumatic drugs.<ref name="pmid26373561">{{cite journal |vauthors=Schau T, Gottwald M, Arbach O, Seifert M, Schöpp M, Neuß M, Butter C, Zänker M |title=Increased Prevalence of Diastolic Heart Failure in Patients with Rheumatoid Arthritis Correlates with Active Disease, but Not with Treatment Type |journal=J. Rheumatol. |volume=42 |issue=11 |pages=2029–37 |date=November 2015 |pmid=26373561 |doi=10.3899/jrheum.141647 |url=}}</ref><ref name="pmid11953961">{{cite journal |vauthors=Van Doornum S, McColl G, Wicks IP |title=Accelerated atherosclerosis: an extraarticular feature of rheumatoid arthritis? |journal=Arthritis Rheum. |volume=46 |issue=4 |pages=862–73 |date=April 2002 |pmid=11953961 |doi= |url=}}</ref> | |||
[[ | |||
'''Atrial fibrillation''' | |||
The risk of [[atrial fibrillation]] is common in patients with [[heart failure]] and [[Coronary heart disease|coronary artery disease]] in [[rheumatoid arthritis]].<ref name="pmid22403267">{{cite journal |vauthors=Lindhardsen J, Ahlehoff O, Gislason GH, Madsen OR, Olesen JB, Svendsen JH, Torp-Pedersen C, Hansen PR |title=Risk of atrial fibrillation and stroke in rheumatoid arthritis: Danish nationwide cohort study |journal=BMJ |volume=344 |issue= |pages=e1257 |date=March 2012 |pmid=22403267 |pmc=3297675 |doi= |url=}}</ref> | |||
'''Aortic insufficiency''' | |||
==Diagnosis of cardiac disease in rheumatoid arthritis== | [[RA]] rarely causes symptomatic [[Aortic regurgitation|AR]], but can as a result of [[granulomatous]] nodules that may form on the [[aortic]] leaflets.<ref>Chand EM, Freant LJ, Rubin JW. Aortic valve rheumatoid nodules producing clinical aortic regurgitation and a review of the literature. Cardiovasc Pathol. Nov-Dec 1999;8(6):333-8.</ref> | ||
'''Pericarditis''' | |||
[[Pericarditis]] is common in active rheumatoid arthritis. Symptomatic patients have RA factor positive.<ref>name="pmid11324775">{{cite journal |vauthors=Guedes C, Bianchi-Fior P, Cormier B, Barthelemy B, Rat AC, Boissier MC |title=Cardiac manifestations of rheumatoid arthritis: a case-control transesophageal echocardiography study in 30 patients |journal=Arthritis Rheum. |volume=45 |issue=2 |pages=129–35 |date=April 2001 |pmid=11324775 |doi=10.1002/1529-0131(200104)45:2<129::AID-ANR164>3.0.CO;2-K |url=}}</ref> | |||
'''Myocarditis''' | |||
[[Myocarditis]] can take the form of either a [[granulomatous]] disease or interstitial [[myocarditis]].<ref name="pmid2724254">{{cite journal |vauthors=Sigal LH, Friedman HD |title=Rheumatoid pancarditis in a patient with well-controlled rheumatoid arthritis |journal=J. Rheumatol. |volume=16 |issue=3 |pages=368–73 |date=March 1989 |pmid=2724254 |doi= |url=}}</ref> | |||
'''Nodules''' | |||
[[Rheumatoid nodules]] are formed in the different parts of the heart such [[pericardium]], [[myocardium]], and valvular structures. Nodules can lead to different kind of symptoms depending upon the location of nodules such as [[syncope]] and [[Conduction disease|conduction]] defects.<ref name="pmid6882034">{{cite journal |vauthors=Ahern M, Lever JV, Cosh J |title=Complete heart block in rheumatoid arthritis |journal=Ann. Rheum. Dis. |volume=42 |issue=4 |pages=389–97 |date=August 1983 |pmid=6882034 |pmc=1001249 |doi= |url=}}</ref> | |||
== Diagnosis of cardiac disease in rheumatoid arthritis == | |||
Various abnormal '''laboratory tests''' are discussed below: | Various abnormal '''laboratory tests''' are discussed below: | ||
*CBC | *[[Complete blood count|CBC]] | ||
**Low hemoglobin | **Low [[hemoglobin]] | ||
**Low hematocrit | **Low [[hematocrit]] | ||
*Troponins-I or Troponins-T are usually raised in the patient with MI | *Troponins-I or Troponins-T are usually raised in the patient with [[ST elevation myocardial infarction|MI]] | ||
*ESR and CRP are | *[[ESR]] and [[CRP]] are raised | ||
*RA factor is positive | *[[RA]] factor is positive | ||
'''ECG''' | '''ECG''' | ||
ECG | ECG changes in [[ST elevation myocardial infarction|MI]] are ST segment changes. In [[pericarditis]], there is diffuse [[ST-segment elevation]] and [[PR segment depression]]. In the conductions defects such [[complete heart block]], it shows [[AV dissociation]]. | ||
'''''Echocardiography''''' | '''''Echocardiography''''' | ||
Echocardiography is useful in measuring in ejection fraction in heart failure and to diagnose pericarditis and myocarditis. | Echocardiography is useful in measuring in ejection fraction in [[heart failure]] and to diagnose [[pericarditis]] and myocarditis. | ||
== Management of various cardiac disease in rheumatic arthritis == | |||
Treatment of pericarditis: | Treatment of pericarditis: | ||
*NSAIDs are best initial therapy. | *[[Non-steroidal anti-inflammatory drug|NSAIDs]] are best initial therapy. | ||
*Glucocorticoids are added if NSAIDs are not effective. | *[[Glucocorticoids]] are added if NSAIDs are not effective. | ||
*Preferred regimen: Prednisone 1 mg/kg PO 24qh. | *Preferred regimen: [[Prednisone]] 1 mg/kg PO 24qh. | ||
Treatment of myocarditis: | Treatment of myocarditis: | ||
*Preferred regimen: Methylprednisolone pulse therapy 500 to 1000 mg PO 24qh for 3 days. | *Preferred regimen: [[Methylprednisolone]] pulse therapy 500 to 1000 mg PO 24qh for 3 days. | ||
Treatment of conductions defects: | Treatment of conductions defects: | ||
*The pacemaker is | *The [[pacemaker]] is preferred the choice of treatment. | ||
==References== | ==References== | ||
Latest revision as of 15:54, 26 April 2018
To review the complete article on rheumatoid arthritis, click here.
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Manpreet Kaur, MD [2]
Overview
The cardiac complications in rheumatoid arthritis are usually due to involvement by rheumatoid nodule, inflammatory mediators and antirheumatic drugs. There is increased risk of coronary atherosclerosis and thereby increasing the risk of heart failure and atrial fibrillation. Other possible complications include pericarditis, myocarditis and conduction defects. Cardiac disease with rheumatoid arthritis can be related to granulomatous proliferation, inflammatory mediators, and antirheumatic drugs . Echocardiography is helpful in diagnosing pericarditis, ejection fraction and endocardial inflammation. Other useful tests are ECG, CBC, ESR, CRP, and troponins. Treatment of underlying cause is important. Treatment of pericarditis include NSAIDs and glucocorticoids. Treatment of myocarditis is methylprednisolone pulse therapy. Pacemakers are used for conduction defects.
Cardiac complications of rheumatoid arthritis
The cardiac complications in rheumatoid arthritis are usually due to involvement by rheumatoid nodule, inflammatory mediators and antirheumatic drugs. There is increased risk of coronary atherosclerosis and thereby increasing the risk of heart failure and atrial fibrillation. Various cardiac complications include:
Coronary artery disease
There is increased risk of coronary artery disease in rheumatoid arthritis. It could be due to chronic inflammation caused by cytokines, lymphocytes, macrophages, and dendritic cells. Other factors responsible are coagulation abnormalities, immune complexes, and oxidative stress.[1][2][3]
Heart failure
The risk of heart failure is relatively more common in patient with coronary artery disease in rheumatoid arthritis. This is caused by left ventricular dysfunction, inflammatory mediators, and antirheumatic drugs.[4][1]
Atrial fibrillation
The risk of atrial fibrillation is common in patients with heart failure and coronary artery disease in rheumatoid arthritis.[5]
Aortic insufficiency
RA rarely causes symptomatic AR, but can as a result of granulomatous nodules that may form on the aortic leaflets.[6]
Pericarditis
Pericarditis is common in active rheumatoid arthritis. Symptomatic patients have RA factor positive.[7]
Myocarditis
Myocarditis can take the form of either a granulomatous disease or interstitial myocarditis.[8]
Nodules
Rheumatoid nodules are formed in the different parts of the heart such pericardium, myocardium, and valvular structures. Nodules can lead to different kind of symptoms depending upon the location of nodules such as syncope and conduction defects.[9]
Diagnosis of cardiac disease in rheumatoid arthritis
Various abnormal laboratory tests are discussed below:
- CBC
- Low hemoglobin
- Low hematocrit
- Troponins-I or Troponins-T are usually raised in the patient with MI
- ESR and CRP are raised
- RA factor is positive
ECG
ECG changes in MI are ST segment changes. In pericarditis, there is diffuse ST-segment elevation and PR segment depression. In the conductions defects such complete heart block, it shows AV dissociation.
Echocardiography
Echocardiography is useful in measuring in ejection fraction in heart failure and to diagnose pericarditis and myocarditis.
Management of various cardiac disease in rheumatic arthritis
Treatment of pericarditis:
- NSAIDs are best initial therapy.
- Glucocorticoids are added if NSAIDs are not effective.
- Preferred regimen: Prednisone 1 mg/kg PO 24qh.
Treatment of myocarditis:
- Preferred regimen: Methylprednisolone pulse therapy 500 to 1000 mg PO 24qh for 3 days.
Treatment of conductions defects:
- The pacemaker is preferred the choice of treatment.
References
- ↑ 1.0 1.1 Van Doornum S, McColl G, Wicks IP (April 2002). "Accelerated atherosclerosis: an extraarticular feature of rheumatoid arthritis?". Arthritis Rheum. 46 (4): 862–73. PMID 11953961.
- ↑ Wållberg-Jonsson S, Cvetkovic JT, Sundqvist KG, Lefvert AK, Rantapää-Dahlqvist S (May 2002). "Activation of the immune system and inflammatory activity in relation to markers of atherothrombotic disease and atherosclerosis in rheumatoid arthritis". J. Rheumatol. 29 (5): 875–82. PMID 12022343.
- ↑ Wållberg-Jonsson S, Cederfelt M, Rantapää Dahlqvist S (January 2000). "Hemostatic factors and cardiovascular disease in active rheumatoid arthritis: an 8 year followup study". J. Rheumatol. 27 (1): 71–5. PMID 10648020.
- ↑ Schau T, Gottwald M, Arbach O, Seifert M, Schöpp M, Neuß M, Butter C, Zänker M (November 2015). "Increased Prevalence of Diastolic Heart Failure in Patients with Rheumatoid Arthritis Correlates with Active Disease, but Not with Treatment Type". J. Rheumatol. 42 (11): 2029–37. doi:10.3899/jrheum.141647. PMID 26373561.
- ↑ Lindhardsen J, Ahlehoff O, Gislason GH, Madsen OR, Olesen JB, Svendsen JH, Torp-Pedersen C, Hansen PR (March 2012). "Risk of atrial fibrillation and stroke in rheumatoid arthritis: Danish nationwide cohort study". BMJ. 344: e1257. PMC 3297675. PMID 22403267.
- ↑ Chand EM, Freant LJ, Rubin JW. Aortic valve rheumatoid nodules producing clinical aortic regurgitation and a review of the literature. Cardiovasc Pathol. Nov-Dec 1999;8(6):333-8.
- ↑ name="pmid11324775">Guedes C, Bianchi-Fior P, Cormier B, Barthelemy B, Rat AC, Boissier MC (April 2001). "Cardiac manifestations of rheumatoid arthritis: a case-control transesophageal echocardiography study in 30 patients". Arthritis Rheum. 45 (2): 129–35. doi:10.1002/1529-0131(200104)45:2<129::AID-ANR164>3.0.CO;2-K. PMID 11324775.
- ↑ Sigal LH, Friedman HD (March 1989). "Rheumatoid pancarditis in a patient with well-controlled rheumatoid arthritis". J. Rheumatol. 16 (3): 368–73. PMID 2724254.
- ↑ Ahern M, Lever JV, Cosh J (August 1983). "Complete heart block in rheumatoid arthritis". Ann. Rheum. Dis. 42 (4): 389–97. PMC 1001249. PMID 6882034.