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KEY FEATURES

ESSENTIALS OF DIAGNOSIS

  • Clinical evidence of rheumatoid arthritis (RA)

  • Pericarditis and myocarditis with characteristic granuloma on biopsy

  • Granulomatous heart valve disease, predominantly of the mitral and aortic valves

GENERAL CONSIDERATIONS

  • RA is a chronic inflammatory disease characterized by specific distal extremity arthritis and arthralgias

  • RA affects women more than men (2–4:1) and occurs in about 1% of the adult population

  • Cardiopulmonary complications are the second leading cause of death after articular complications

  • The characteristic cardiac lesion consists of granulomas involving all parts of the heart

  • Clinically, cardiac disease is seen in about one-third of patients and involves all parts of the heart and blood vessels (vasculitis)

  • Cardiovascular disease is more commonly found in older male patients with evidence of active inflammation

  • RA also predisposes patients to atherosclerotic cardiovascular disease

CLINICAL PRESENTATION

SYMPTOMS AND SIGNS

  • Characteristic chest pain of pericarditis or myocardial ischemia

  • Dyspnea on exertion, fatigue

  • Palpitation

PHYSICAL EXAM FINDINGS

  • Pericardial friction rub

  • Murmurs of valvular heart disease

  • Evidence of heart failure

  • Evidence of pulmonary hypertension

DIFFERENTIAL DIAGNOSIS

  • Other causes of acute pericarditis or myocarditis

  • Other causes of valvular heart disease

  • Other connective tissue diseases

  • Other causes of pulmonary hypertension

DIAGNOSTIC EVALUATION

LABORATORY TESTS

  • Positive rheumatoid factor, high erythrocyte sedimentation rate (> 55 mm/hour)

  • Pericardial fluid is exudative with high protein, lactate dehydrogenase, and rheumatoid factor, but low glucose

  • Cardiac biomarkers: elevated myocardial creatine kinase and troponins

ELECTROCARDIOGRAPHY

  • Diffuse nonspecific ST-T–wave changes are most common

  • ST-segment elevation may be seen in pericarditis and myocardial infarction

  • Conduction disturbances in some

  • Right ventricular hypertrophy if pulmonary pressures are elevated

IMAGING STUDIES

  • Chest x-ray:

    • – Cardiomegaly may be seen

  • Echocardiography:

    • – Pericardial effusion with pericarditis

    • – Valve thickening (diffuse and nodular)

    • – Valve regurgitation

    • – Left ventricular dysfunction

    • – Segmental wall motion abnormalities

    • – Evidence of pulmonary hypertension

  • Cardiac MRI or CT scans are excellent for detecting pericardial thickening

  • Cardiac MRI is excellent for detecting myocarditis

DIAGNOSTIC PROCEDURES

  • Lung biopsy may be necessary to diagnose pulmonary vasculopathy as the cause of pulmonary hypertension

  • Cardiac biopsy may be required to diagnose myocarditis

  • Stress myocardial imaging studies to evaluate possible coronary artery disease

  • Coronary angiography in selected cases

  • Ambulatory ECG monitoring may be needed to diagnose significant conduction abnormalities or arrhythmias

TREATMENT

CARDIOLOGY REFERRAL

  • Acute pericarditis

  • Acute myocardial ischemia or infarction

  • Significant valve disease

  • Left ventricular dysfunction or heart failure

  • Significant conduction abnormalities or arrhythmias

HOSPITALIZATION CRITERIA

  • Acute pericarditis

  • Heart failure

  • Third-degree heart block

  • Acute myocardial ischemia or infarction

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