The heart in rheumatoid arthritis

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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:

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:

Treatment of myocarditis:

Treatment of conductions defects:

  • The pacemaker is preferred the choice of treatment.

References

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Sigal LH, Friedman HD (March 1989). "Rheumatoid pancarditis in a patient with well-controlled rheumatoid arthritis". J. Rheumatol. 16 (3): 368–73. PMID 2724254.
  9. 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.



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