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Chapter 100: Rheumatologic Diseases and the Cardiovascular System

A 55-year-old woman presents to the emergency department with positional chest pain, worse with lying flat and with inspiration. On physical exam, she is noted to have a symmetrical polyarthritis affecting the small joints of her hands and feet, including a swan-neck deformity of the fingers, ulnar deviation of the metacarpophalangeal joints, and a boutonniere deformity of the thumb. The most common cardiovascular manifestations of this systemic autoimmune disease include all of the following except:

A. Conduction system disease

B. Pericarditis

C. Valvular disease

D. Cardiomyopathy

E. Coronary vasculitis

The answer is A. (Hurst’s The Heart, 14th Edition, Chap. 100) The patient has a diagnosis of RA. Extra-articular manifestations of RA include fatigue, low-grade fever, Sjögren syndrome, rheumatoid nodules, interstitial lung disease, and vasculitis. Electrical conduction disorders are not specifically seen as a result of RA. Other systemic autoimmune disorders, including inflammatory myopathies (characterized by proximal muscle weakness with dermatomyositis and Gottron papules) and systemic sclerosis (where the limited form is referred to as CREST), are associated with conduction system abnormalities. In RA, the most common cardiovascular manifestations are pericarditis, valvular disease, specifically mitral valve insufficiency (option C), cardiomyopathy characterized by focal necrotizing or granulomatous myocarditis (option D), coronary vasculitis (option E) where as many as 20% of patients show histologic evidence by autopsy, and accelerated coronary artery atherosclerosis and heart failure.

A 60-year-old woman with rheumatoid arthritis (RA) is sent to you for discussion about her overall risk of developing coronary artery disease. Which of the following statements is correct?

A. 10% of deaths in RA are attributable to cardiovascular disease

B. The prevalence of cardiovascular disease is higher in patients with RA than in diabetics

C. When compared with controls, women with RA have a fivefold higher rate of myocardial infarction

D. Systemic inflammation in RA is hypothesized to accelerate atherosclerosis

E. The C-reactive protein normalizes in most patients with RA who are judged to be in clinical remission

The answer is D. (Hurst’s The Heart, 14th Edition, Chap. 100) The overall mortality is increased in patients with RA,1,2 with 40% of deaths attributable to cardiovascular disease (option A).3,4 In a recent study, the prevalence of cardiovascular disease in RA patients was comparable to that of patients with diabetes (option B).5 It is known that a significant proportion of patients with RA judged ...

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