THE HEART AND RHEUMATOLOGIC DISEASEby DR SANAT PATHAK
Rheumatologic diseases are truly multisystem diseases and the heart is closely linked to most. Many rheumatic diseases have cardiovascular complications and manifestations. Apart from manifestations of the diseases themselves, they have accompanying atherosclerosis and increased risk of ischemic events.
Heart involvement as a disease manifestation:
In some autoimmune diseases, the heart may be involved as part of the inflammatory disease process itself, leading to symptoms and complications. Takayasu arteritis can involve the left ventricle along with the aorta. Some patients with severe Systemic lupus erythematosus (SLE)
are known to have myocarditis, that is inflammation of the heart muscle itself, leading to reduced ability to pump blood. The right side of the heart is often involved in Systemic sclerosis, leading to pulmonary arterial hypertension.
Patients with severe PAH present with swelling over the feet and fluid in the abdomen. Diseases may involve specific structures; such as the heart valves alone in rheumatic fever and antiphospholipid syndrome. The coverings of the heart, the pericardium, can get inflamed in rheumatoid arthritis and SLE too, producing pain and breathlessness.
Coronary artery disease as a complication in rheumatologic illnesses:
Coronary artery disease results from narrowing of the arteries supplying the heart leading to ischemia. This process may be long standing but compensated, leading to angina; a sudden occlusion of a coronary artery due to a blood clot leads to a myocardial infarction, often termed a 'heart attack'. lschemic heart disease is the most common cause of death worldwide; the prevalence is increasing in India rapidly in the last 60 years.
'Traditional' risk factors for CAD are well known and include obesity, high blood pressure, diabetes and lipid profile abnormalities such as high cholesterol. However, rheumatic diseases themselves are risk factors too. Rheumatoid arthritis and ankylosing spondylitis both increase the risk of a new cardiovascular event by 1. 5 to 2 times, which is equivalent to the risk conferred by diabetes. Young ladies with SLE are especially susceptible; a study showed that women aged 35- 45 years had a 50 times higher risk of developing a coronary event as compared to healthy women of similar age. The presentation of CAD might differ as well: many myocardial infarctions in RA were 'silent', viz not accompanied by the typical symptoms of chest pain, chest discomfort. The increased risk of CAD in patients with rheumatic diseases cannot be explained only by the presence of comorbidities such as hypertension or metabolic syndrome, and it is currently felt that inflammation itself increases the risk of atherosclerosis in the arteries and plaque rupture.
What can be done to mitigate risk?
Screening for heart disease is simple, inexpensive and can flag a problem before it becomes threatening. Screening involves looking at other risk factors (lipid levels, blood pressure) , ECG , stress tests and echocardiography as felt relevant in individual patients. Newer modalities such as cardiac CT scans and carotid artery dopplers may add information too.
2. Multi-disciplinary care:
A new symptom of chest pain, breathlessness - especially on exertion, excessive fatigue, swelling on the legs may herald the onset of heart disease. Request a referral to a cardiologist, as early detection can avoid unnecessary hospitalisations and complications later.
3. Special situations:
Screening for heart disease is pertinent in patients in situations such a pregnancy or requiring general anesthesia, in which even subclinical disease may produce complications.
4. Disease control
Uncontrolled rheumatic disease and the accompanying inflammation worsen cardiac outcomes. A good control of disease activity reduces the risk of cardiovascular disease. This includes optimum and sustained use of medication. Contrary to popular misconceptions, drugs like methotrexate are protective of the heart and reduce the risk of coronary artery disease. On the contrary, self-medicating with glucocorticoids at higher doses (> 10 mg) and anti inflammatories increase risk.
Exercise is beneficial in both regaining function after a rheumatic disease, as well as reducing heart disease risk. Muscle strengthening, adipose tissue loss are all known to reduce risk.
Half the problem is tackled when the patient and the team of care givers, both medical personnel and those at home, are aware of the increased risk of heart disease conferred by rheumatologic disease.