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==Overview==
==Overview==
People with rheumatoid arthritis are more prone to [[atherosclerosis]], and risk of [[myocardial infarction]] and [[stroke]] is markedly increased.[6] Other possible complications that may arise include: [[pericarditis]], [[endocarditis]], left ventricular failure, valvulitis and fibrosis.<ref name="pmid8147925">{{cite journal |author=Wolfe F, Mitchell DM, Sibley JT, ''et al'' |title=The mortality of rheumatoid arthritis |journal=Arthritis Rheum. |volume=37 |issue=4 |pages=481–94 |year=1994 |month=April |pmid=8147925 |doi= |url=}}</ref> Cardiac disease with [[rheumatoid arthritis]] can be related to granulomatous proliferation or [[vasculitis]]. Echocardiography has made diagnosing [[pericarditis]] and endocardial inflammation easier.
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.


=== '''Various cardiac complications of rheumatoid arthritis are discussed below''': ===  
== Cardiac complications of rheumatoid arthritis ==
The cardiac complications in rheumatoid arthritis are due to involvement by rheumatoid nodulosis. There is increased risk of coronary atherosclerosis and thereby increasing the risk of heart failure and atrial fibrillation. Various cardiac complications include:
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==
'''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.<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==
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>
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==
'''Heart failure'''
The risk of atrial fibrillation is common in patients with heart failure and 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 insuuficiency==
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>
[[RA]] rarely causes symptomatic 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==
'''Atrial fibrillation'''
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==
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>
Myocarditis can take the form of either a granulomatous disease or interstitial myocarditis.  Granulomatous involvement of the heart is localized and is specific for the rheumatoid involvement of the heart. Myocarditis, in contrast, involves not localized but diffuse infiltration of the myocardium by mononuclear cells, may involve the entire myocardium and yet have no clinical manifestations.<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>


==Amyloidosis==
'''Aortic insufficiency'''
Amyloidosis in RA has been reported in numerous case-series studies to be present in a high variation of frequency, probably due to patients’ selection. <ref>Wiland P, Wojtala R, Goodacre J, Szechinski J. The prevalence of subclinical amyloidosis in Polish patients with rheumatoid arthritis. Clin Rheumatol 2004;23:193–98.</ref> Amyloidosis occurs preferentially in male patients with a longer disease duration. The relevance of cardiac involvement including cardiac amyloidosis is illustrated by the high frequency of cardiac failure as a cause of mortality in RA patients treated with hemodialysis <ref>Kuroda T, Tanabe N, Harada T et al. Long-term mortality outcome in patients with reactive amyloidosis associated with rheumatoid arthritis. Clin Rheumatol 2005;3:1–8.</ref>. Intensified immunosuppressive treatment should be considered if a RA patient is diagnosed with amyloidosis.
 
[[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:
*[[Complete blood count|CBC]]
**Low [[hemoglobin]]
**Low [[hematocrit]]
*Troponins-I or Troponins-T are usually raised in the patient with [[ST elevation myocardial infarction|MI]]
*[[ESR]] and [[CRP]] are raised
*[[RA]] factor is positive
'''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 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:
*[[Non-steroidal anti-inflammatory drug|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.


==Endocardial Inflammation==
Echocardiographic studies have reported evidence of previously unrecognized [[mitral valve]] disease diagnosed by a reduced E-F slope of the anterior leaflet of the [[mitral valve]]. Although [[aortic valve]] disease and arthritis are generally associated through [[ankylosing spondylitis]], a number of patients with granulomatous nodules on the valve have been reported <ref>Iveson JM, Thadani U, Ionescu M, et al: Aortic valve incompetence and replacement in rheumatoid arthritis. Ann Rheum Dis  1975; 34:312-320.</ref>
===Management of conduction disturbances in rheumatic diseases===
[[Pacemaker]] implantation is the method of choice for the treatment of [[complete heart block]] and other serious conduction abnormalities. Sophisticated pacing modalities and programmability as well as low-energy circuitry and new battery designs have increased device longevity and enabled wide clinical application. A simple VVI pacemaker (paces and senses the ventricle and is inhibited by a sensed ventricular event) may be adequate for transient or infrequent bradyarrhythmia. For frequent or persistent bradyarrhythmia, prolonged dependence on ventricular pacing may warrant use of a rate-responsive demand unit or, if no atrial or sinus node abnormalities are present, a dual-chamber system (DDD—both chambers are capable of being sensed and paced). New devices enable resynchronization therapy in patients with [[dilated cardiomyopathy]] and severely impaired contractility, with beneficial effect on haemodynamics and long-term survival.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 15:54, 26 April 2018

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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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