Cardiac manifestations of rheumatologic disorders

1

What is the leading cause of mortality in patients with rheumatoid arthritis (RA) and what are the most common cardiac manifestations of RA?

• Ischemic heart disease is the leading cause of mortality in patients with RA. Compared to the general population, patients with RA have a 50% increased risk of cardiovascular mortality. Other common cardiac manifestations of RA include pericarditis, myocarditis, and valvular thickening resulting in aortic and/or mitral insufficiency.

2

What pathophysiologic mechanisms contribute to accelerated atherosclerosis in patients with RA?

• As depicted in Fig. 47.1 , chronic release of proinflammatory cytokines (e.g., tumor necrosis factor-α [TNF-α], interferon-γ [IFN-γ], interleukin-1 [IL-1], IL-6) in patients with RA is associated with an adverse lipid profile, insulin resistance, hypercoagulability (e.g., elevated fibrinogen and plasminogen activator inhibitor [PAI]-1), and direct activation of the endothelium and subendothelial macrophages. Together, these effects result in accelerated formation of high-risk atherosclerotic plaques (e.g., thin fibrous cap) that increase the risk of acute coronary syndromes in patients with RA.

  

3

What are the most common cardiac manifestations of systemic lupus erythematosus (SLE)?

• Pericarditis is the most common cardiac manifestation of SLE and can occur with or without a pericardial effusion. Nonbacterial thrombotic endocarditis (NBTE) is also common, particularly in patients with antiphospholipid antibodies. As shown in Fig. 47.2 , the vegetations seen in NBTE are generally small and most often affect the mitral valve. These vegetations carry a high risk of thromboembolism, necessitating lifelong anticoagulation. Lastly, SLE is an independent risk factor for premature coronary artery atherosclerosis, particularly in patients with antiphospholipid antibodies, lupus nephritis, and/or severe disease activity.

  

4

Which cardiovascular medications carry the highest risk of drug-induced lupus?

• The annual incidence of drug-induced lupus is 15% to 20% in patients taking procainamide (a class Ia antiarrhythmic) and 5% to 10% in patients taking hydralazine (a direct smooth muscle cell relaxant), placing these two drugs in the highest risk category. Quinidine (another class Ia antiarrhythmic) also carries a moderate risk of drug-induced lupus.

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