Cardiac manifestations of rheumatoid arthritis are an extra-articular feature of rheumatoid arthritis and are considered prognostically more severe.
For a general discussion of rheumatoid arthritis and a particular discussion of its respiratory and musculoskeletal manifestations, please refer to the respective dedicated article.
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Epidemiology
Rheumatoid arthritis is considered an independent factor for many different cardiac and vascular diseases and because of that, it is associated with increased mortality compared to the general population 1-3.
Associations
Rheumatoid arthritis is associated with the following cardiovascular manifestations 1,2:
- pericarditis/pericardial effusion (in about 10%, more common in men)
- myocarditis
- cardiomyopathy
- congestive heart failure
- rheumatoid nodules/granuloma
- cardiac amyloidosis
- coronary vasculitis
- arrhythmia
- valvular heart disease (mitral valve insufficiency, aortic valve insufficiency)
- autoimmune endocarditis
Clinical presentation
Cardiac manifestations of rheumatoid arthritis typically cause cardiovascular symptoms like chest pain, dyspnea, palpitations, dizziness or syncope.
Complications
Typical complications of cardiovascular manifestations of rheumatoid arthritis include the following conditions 1-3:
- myocardial ischemia and myocardial infarction
- sudden cardiac death (twice the likelihood of the general population)
Pathology
Shared inflammatory and immune mediators between rheumatoid arthritis and cardiovascular disease seem to play a role in the pathogenesis.
Radiographic features
Radiographic features can be quite variable and are more subject to the respective cardiac or vascular manifestation than to the modality. Nevertheless
Echocardiography
Echocardiography is usually the first-line imaging modality for the evaluation of any suspected cardiac involvement and will aid in the assessment of the following:
- diastolic and systolic dysfunction
- valvular heart disease including valvular thickening and nodules
- pericardial effusion and/or pericardial thickening
CT
Cardiac CT can help in the evaluation of suspected coronary artery disease or signs of vasculitis. In addition, valvular nodules or other abnormalities might be depicted.
MRI
Cardiac MRI will provide valuable information regarding cardiac function and cardiac tissue characterization and will aid in the diagnosis of associated myocardial and pericardial disease.
Radiology report
The radiological report should include a description of the following:
- cardiac volumes and measurements
- cardiac wall motion abnormalities
- pericardial thickening and/or pericardial effusion indicating pericarditis
- valvular disease including nodules and thickening
- signs of myocarditis if present based on Lake Louise criteria
- signs of cardiac amyloidosis if present
Treatment and prognosis
Management of cardiac manifestations and cardiovascular risk in patients with rheumatoid arthritis is quite complex includes the control of disease activity as well as general preventive measures of major cardiac events and lifestyle modifications on one hand and the therapy of the underlying cardiac problem on the other hand. Depending on the cardiac manifestation this might include:
- pericarditis: aspirin or NSAIDs if mild, glucocorticoids or interventional measures in more severe cases
- myocarditis: glucocorticoids or immunosuppressive therapy in non-responders
- autoimmune endocarditis: might need valve replacement if severe