The aim of the study was to describe echocardiographic abnormalities in patients with rheumatoid arthritis, concurrent systemic comorbidities, rheumatologic clinical activity, serologic markers of rheumatoid arthritis, and inflammatory activity. In an observational, cross-sectional study, rheumatoid arthritis outpatients were included ( n = 105).
Conventional transthoracic echocardiographic variables were compared between patients with arthritis and non-RA controls ( n = 41). For rheumatoid arthritis patients, articular activity and rheumatologic and inflammatory markers were obtained. Ventricular dysfunction was found in 54.3% of the population: systolic (18.1%), diastolic (32.4%), and/or right (24.8%), with lower ejection fraction ( P. BackgroundRheumatoid arthritis (RA) is a chronic inflammatory disease –, and even though its major characteristic is polyarticular affection it is associated with such extra-articular features as vasculitis, keratoconjunctivitis sicca, bronchiolitis obliterans, organizing pneumonia, portal fibrosis, secondary amyloid, and cryoglobulinemia. It has also been associated with increased cardiovascular risk due to conduction and valve alterations, heart failure, and premature atherosclerosis –.Multiple studies have shown that accelerated and increased atherosclerosis in autoimmune diseases leads to ischemic coronary artery disease. The proposed mechanisms for this are a major systemic inflammatory state involving T cell lymphocytes, tumor necrosis factor alpha (TNF alpha), high density lipoprotein dysfunction, and treatment related hyperhomocysteinemia.
All of these factors lead to thickening of arterial intima, myocardial dysfunction, and in some cases myocardial infarction and are responsible for up to 50% of deaths in this population.RA has been linked to several structural heart abnormalities, including increased right ventricular filling pressure, left ventricular hypertrophy, pulmonary artery hypertension, and as much as twice the prevalence of heart failure ,. However, many patients have been found to develop asymptomatic diastolic dysfunction demonstrated by echocardiographic studies and by cardiac magnetic resonance. Found that mean LV mass was strikingly lower in RA compared to controls , so RA patients represent an important target population for early management in strategies to reduce progression to advanced heart failure.Cardiovascular risk and RA disease activity assessment through clinical judgment and appropriate questionnaires in addition to inflammatory markers may provide adequate screening tools to predict heart disease in RA patients, even in asymptomatic stages, which eventually will lead to early, cost effective studies and treatment. Statistical AnalysisData are presented as mean ± standard deviation for continuous variables with similar distribution to the normal curve. In the case of categorical variables, data are presented as absolute and relative frequencies.
Study population was classified in two groups: patients with RA and ventricular dysfunction and patients with RA without ventricular dysfunction. The groups were compared with a Student's t-test for independent samples or chi-square according to the type of variable. Echocardiographic findings of patients with RA were compared to those of a control group without RA. ResultsIn the present study 105 patients with RA were included; the female gender (79%) was predominant.
Hypertension (51.4%), coronary artery disease (27.6%), and diabetes (17%) were the most frequent cardiovascular risk factors.Fatigue (42.9%), shortness of breath (49.5%), and edema (39%) were the main symptoms reported potentially associated with heart failure. From the rheumatologic perspective, most patients were in functional categories 1 or 2, with no significant limitations of daily activities. According to the DAS questionnaire, most patients had high or intermediate disease activity at the time of evaluation, 30.5% high and 42.9% intermediate activity. Glucocorticoids, folic acid antagonist (methotrexate), and other disease modifying antirheumatic drugs (DMARD) were used in 26.7% of the patients.Among the echocardiographic findings, patients with RA had lower ejection fractions, greater left atrial and aortic diameters, ventricular septum and left ventricular posterior wall thickness, and right ventricular and atrial diameters. Pulmonary systolic arterial pressure (PSAP) was also increased in comparison to control subjects.
VariablePatients with RAn = 105Controlsn = 41PAge (years)62.4 ± 14.657.4 ± 13.90.09Gender (male/female), n (%)22 (21)/83 (79)10 (24.4)/31 (75.6)0.65Shortening fraction (%)35.8 ± 8.639.4 ± 11.80.06Ejection fraction (%)60.0 ± 12.167.7 ± 5.8. Echocardiographic abnormalities indicating ventricular dysfunction were found in 54.3% of the population, including left systolic (18.1%), diastolic (32.4%), and/or right (24.8%) ventricular dysfunction.
It was also frequent to observe pulmonary hypertension (46.9%).When patients with RA without ventricular dysfunction were compared to RA patients with ventricular dysfunction, the latter were older, but there were no differences between the groups with respect to the duration of rheumatologic disease. Angina and myocardial infarction, diabetes, and dyslipidemia were frequently found in the patients with ventricular dysfunction.
However, serum cholesterol concentrations were lower in patients with ventricular dysfunction, although, LDL cholesterol was slightly higher. HDL concentrations were similar in both groups. VariablesVentricular dysfunctionn = 57No ventricular dysfunctionn = 48PAge (years)65.4 ± 14.158.8 ± 14.60.02Habitual weight (kg)65.1 ± 10.963.0 ± 11.20.36Body mass index (kg/m 2)23.6 ± 9.124.0 ± 8.80.83Rheumatoid arthritis evolution time18.87 ± 12.5415.09 ± 11.120.11Cancer (%)9.6140.51Coronary artery disease (%)45.311.9. Data are expressed as%, mean ± standard deviation, or median (percentile 50–75).With respect to rheumatoid factor and anti-CCP antibodies levels, these were also significantly elevated in cases with ventricular dysfunction, despite similar erythrocyte sedimentation rates in the two groups.The use of glucocorticoids, folic acid antagonist (methotrexate), or other DMARDs was not different across RA groups, while treatment with beta blockers, diuretics, digitalis, and nitrates was significantly more prevalent in those patients with echocardiographic anomalies ( P. DiscussionHeart disease in patients with rheumatoid arthritis remains one of the main causes of death in this population ,. In the present study structural heart disease (biventricular abnormalities and pulmonary hypertension) was found in 53% of the patients in this study. These echocardiographic findings in a Mexican population with rheumatoid arthritis agree with those reported in patients from Italy, Poland and the United Kingdom ,.
Diastolic dysfunction was the most common functional alteration along with pulmonary artery hypertension as previously reported ,. Major variables associated with structural heart disease were increased such as age, cardiovascular disease, and diabetes mellitus as clinical entities. Among the laboratory parameters we found that rheumatoid factor and anti-CCP antibodies correlated with echocardiographic findings, as Vizzardi and Cavazzana described.Another interesting finding was that treatment with DMARDS, folic acid antagonists, glucocorticoids, and folic acid supplements was not significantly different between RA patients with asymptomatic ventricular dysfunction and those without.
Artritis Reumatoide Sintomas
To be sure, treatment with beta blockers, diuretics, digitalis, and nitrates was significantly more prevalent in those patients with echocardiographic anomalies ( P. ConclusionThe present study illustrates that some rheumatoid arthritis patients present structural heart abnormalities that will probably progress to heart failure. These abnormalities appear to be more common in patients with a history of coronary artery disease and diabetes, longer disease duration, and increased serologic markers of rheumatoid arthritis. Focused assessment directed toward heart failure screening based on clinical judgment and echocardiography in a population with the former characteristics offers an opportunity for appropriate and early management of heart disease.