Alena Dutko / SHUTTERSTOCK.COM
SAN DIEGO—It’s no secret: Autoimmune, inflammatory rheumatic disease raises a patient’s risk of cardiovascular disease (CVD).
“Inflammation may affect all aspects of the cardiac structure and function,” said Rekha Mankad, MD, FACC, director of the Women’s Heart Clinic at the Mayo Clinic in Rochester, Minn. Dr. Mankad also oversees a cardio-rheumatology clinic to assess and treat these complex patients. On Nov. 6 at the ACR/ARHP Annual Meeting, she discussed heart disease risk assessment and complications in rheumatic diseases. Rheumatoid arthritis patients have the highest CVD risk, followed by those with inflammatory bowel diseases.1 Survival rates are lower in RA patients due to heart disease.2
“We see this risk in lupus as well. Rheumatologists have become incredibly good at treating lupus, so very active, early disease doesn’t take the lives of these patients, but as they live longer, heart disease is the reason for late deaths,” said Dr. Mankad.3 Ankylosing spondylitis patients may have higher rates of vascular death because AS often causes aortitis and aortic regurgitation.4 Lupus elevates a patient’s risk for pericardial effusion, which is often asymptomatic. Pericarditis usually happens during active lupus flares.
Valve Choice Matters
Antiphospholipid antibody syndrome, frequently seen in lupus, may cause valvular complications like Libman-Sacks endocarditis or nonbacterial thrombotic endocarditis (NBTE). Its bland lesions are filled with immune complexes, fibrin and platelet thrombi.
“Why are these lesions important to recognize? Because you must figure out the right valve replacement choice. We are talking about a young patient population in lupus, women who are potentially in their childbearing years,” she said. Mechanical valves are preferable to bioprosthetic valves in this population, although it is important to carefully manage anticoagulation, especially if patients become pregnant.
Valve disease occurs in up to 20% of lupus patients and can worsen over time, she said. “This may be a population where we should be doing echocardiograms at baseline, although that’s not part of the guidelines.” Even healed lesions may lead to fibrosis later, she said.
Heart failure risk is also higher in RA.5 “As we age, everyone’s heart failure risk goes up, but if you have RA, that risk goes up dramatically,” she said. One study showed that RA patients’ inflammatory markers peaked six few months before their diagnoses.6 “This tells us that inflammation, which we know affects the joints and all parts of the body, certainly affects the myocardium and makes these patients more prone to heart failure.”