The connective tissue diseases are immune-mediated inflammatory diseases, primarily of the musculoskeletal system; however, they frequently also involve the cardiovascular system. The most important of these diseases are systemic lupus erythematosus, rheumatoid arthritis, scleroderma, ankylosing spondylitis, polymyositis/dermatomyositis, and mixed connective tissue disease. They affect the valve leaflets, coronary arteries, pericardium, myocardium, conduction system, and great vessels with different rates of prevalence and degrees of severity. Although heart involvement in patients with connective tissue diseases contributes significantly to their morbidity and mortality rates, there is a large discrepancy between clinically recognized heart disease, echocardiography studies, and postmortem series. Furthermore, their pathogenesis and natural history are still incompletely understood, and their therapy is not yet standardized. Increased awareness and better understanding of the cardiovascular diseases associated with connective tissue diseases may lead to earlier recognition and treatment with consequent decreased morbidity and mortality. Finally and of importance, patients with connective tissue diseases and associated heart disease should be managed by both cardiologists and rheumatologists given the potential morbidity and mortality of their heart disease and the complexity and potential harm of their pharmacotherapy.
Systemic Lupus Erythematosus
ESSENTIALS OF DIAGNOSIS
Musculoskeletal and mucocutaneous manifestations of systemic lupus erythematosus (SLE).
Libman-Sacks vegetations and atrioventricular (AV) valve regurgitation.
Intra- and extracardiac thrombosis and cardioembolism.
Acute pericarditis/myocarditis with antinuclear antibodies detected in the pericardial fluid.
Systemic lupus erythematosus (SLE) is a multisystem chronically recurrent inflammatory disease that affects the musculoskeletal, mucocutaneous, visceral, and central nervous systems. Symptoms include fatigue, myalgias, arthralgias or arthritis, photosensitivity, and serositis. The prevalence of SLE varies widely, from 4 to 250 cases per 100,000 persons. It is more frequent in a patient’s relatives than in the general population. SLE is predominantly seen in females, with a female-to-male ratio of 10:1. The pathophysiology of the disease is related to the multiorgan deposition of circulating antigen–antibody complexes and activation of the complement system, leading to humoral- and cellular-mediated inflammation.
Although SLE affects the cardiovascular system with varied frequency and degrees of severity, cardiovascular disease is the third most important cause of death in SLE patients (after infectious and renal diseases) during the earlier course of disease, but later on, cardiovascular disease is a predominant cause of their death. The most significant SLE-associated heart diseases are valvular heart disease, arterial or venous thrombosis and systemic thromboembolism, premature coronary artery disease (CAD), and pericarditis. Myocarditis or cardiomyopathy and cardiac arrhythmias or conduction disturbances are less common.
Regarding the pathogenesis of SLE-associated cardiovascular disease, it is believed, as it is for the primary disease, that the immune complex deposition and complement activation lead to an acute, chronic, or recurrent inflammation of the valve leaflets, endocardium, vascular endothelium, pericardium, myocardium, or conduction system. The presence in these tissues of immune complexes, complement, antinuclear antibodies, lupus erythematosus cells, mononuclear inflammatory cells, necrosis, hematoxylin bodies, and deposits ...