Arthritis and Cardiovascular Disorders

by Dr. Jagdish Hiremath

Arthritis is a broad term and roughly it can be divided into rheumatic arthritis and rheumatoid arthritis. Rheumatic arthritis occurs in childhood between the age of 5 and 15 years. It is more common in girls. It licks the joint and bites the heart. During the active arthritis phase, there is swelling and pain in bigger joints of the limbs. It passes off within a few days by symptomatic treatment and no abnormality of the joint is seen ever. The immune complexes of the arthritis lodge themselves on the heart valves and over a period of next many years the heart valve gets defective and causes valvular heart disease. Therefore it is known to lick the joint (leave it unscathed completely) but bites the heart (causing valvular heart disease)..

Rheumatoid arthritis however affects adults & affects the small joints. It leaves deformity of the joint and involvement of the heart in rheumatoid arthritis is never to a great extent. Rheumatoid arthritis causes fluid in the layer which surrounds the hearts (pericardial effusion). It is a painful condition and is diagnosed by echocardiography. It requires only symptomatic treatment and improvement in the treatment for rheumatoid arthritis. It does not cause any bad consequences. Very rarely rheumatoid arthritis can get involvement of the aortic valve of the heart. This fortunately is rare and therefore generally rheumatoid is not considered as one of the important causes of cardiac involvement.

This disease was rampant in India in all these decades but in the last five years it is definitely showing a declining trend. The disease is related to low socio-economic status, crowded rooms and unhygienic conditions. It is a bacterial infection which spreads from one to the other due to the above conditions. Penicillin injections are given to this arthritis initially everyday for 10 days and later on every 15 days for one year and later on every 3 weeks till the age of 25 years. Till few years ago “Penicillin Prophylaxis” injections were compulsory life long. Now with improvement in the socio-economic status of the country, government directive is to stop Penicillin injections at the age of 25 unless it is in a special populations.

Mitral valve is the valve between the left auricle and the left ventricle of the heart. It is the commonest affected valve by rheumatic arthritis. The valve can get narrowed down (stenosis) or can start leaking (regurgitation). If the involvement is mild, medical treatment is continued and the person is observed by echocardiography year after year. If the regurgitation becomes severe or the heart starts getting enlarged or if the person gets out of breath very easily, a valve replacement surgery or sometimes a valve repair surgery has to be performed. This is an open heart surgery and a success rate is reasonably good.

If the valve gets narrowed (mitral stenosis) balloon mitral valvuloplasty is performed without operation. “BMV” is a common procedure. Once done, the effect of BMV lasts for about 5- 7years after which the valve can get narrowed down again.

The person who has rheumatic valvular heart disease needs to be under medical supervision and needs to undergo echocardiography atleast yearly. Nutrition needs to be maintained well with high protein diet, maintaining good hemoglobin levels and good muscular strength. The exertion is allowed depending on the severity of the valvular involvement. Pregnancies and delivaries can cause a problem if the mother is suffering from valvular heart disease. Special precautions need to be taken before a pregnancy and deliveries undertaken.

Aortic valve also gets involved in rheumatic fever. It is also either in the form of stenosis or regurgitation. If severe there is no balloon procedure for aortic valve, it needs to be replaced with an artificial valve and this open heart surgery also has good success rate.

Pulmonary and tricuspid valve don't get involved in rheumatic heart disease.

But many a times both aortic and mitral valve can get affected and may require to undergo double valve replacement. Thus majority of the cardiovascular involvement related to arthritis is due to rheumatic fever. It is a niggling disease to have and the person and family needs to be prepared mentally to live with the disease life long.

Advanced treatments are available. They have excellent success rate. They are expensive but they can lead to excellent quality and quantity of life. (If the patient is diagnosed correctly at a correct time and is subjected to procedures a proper time)

Prevention of rheumatic arthritis is definitely possible. It involves more hygienic areas, less crowded rooms and fresh air exercises and good nutritional valve food, maintaining immunity of the body. If the arthritis is diagnosed at a correct stage and treated properly with Penicillin injections the development of the valvular heart disease also can be prevented to a large extent.

Left : Normal mitral valve opening, thin leaflets: MV area 3.7cm2

Right : Rheumatic mitral "Stenosis", thick leaflets: MV area 1 cm2

Left : Normally closed mitral valve. Normal sized of chambers. No “leakage” (Regurgitation) Right : Thickened MV – improper closure. Enlarged LA & LV. Significant Regurgitation