Rheumatoid Arthritis and the Heart

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