The heart in rheumatoid arthritis

Associate Editor:

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. Cardiac disease with rheumatoid arthritis can be related to granulomatous proliferation or vasculitis. Echocardiography has made diagnosing pericarditis and endocardial inflammation easier.

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.

Aortitic Insufficiency
RA rarely causes symptomatic AR, but can as a result of granulomatous nodules that may form on the aortic leaflets.

Pericarditis
Infrequently diagnosed on the basis of history and physical examination in RA, pericarditis is present in up to 50% of patients at autopsy. In one study, 31% of patients with RA had echocardiographic evidence of pericardial effusion. The same study revealed only rare evidence of impaired left ventricular function in prospectively studied outpatients with RA. Although unusual, cardiac tamponade with constrictive pericarditis develops in RA and may require pericardectomy. Almost all patients have a positive test for RF, and half have nodules. The preservation of good ventricular function on echocardiography in the face of deteriorating clinical myocardial function should raise a high index of suspicion of constrictive pericarditis.

Myocarditis
Myocarditis can take the form of either a granulomatous disease or interstitial myocarditis. Granulomatous involvement of the heart is localized, and is specific for 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.

Amyloidosis
Amyloidosis in RA has been reported in numerous caseseries studies to be present in a high variation of frequency, probably due to patients’ selection. 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 haemodialysis. Intensified immunosuppressive treatment should be considered if a RA patient is diagnosed with amyloidosis.

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