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Rouached L, Tekaya R, Ben Ayed H, Bouden S, Ben Tekaya A, Ben Ahmed H, Mahmoud I, Saidane O, Abdelmoula L. Screening of silent myocardial ischaemia using a stress test in rheumatoid arthritis patients: Association with traditional risk factors and disease activity. Musculoskeletal Care 2023; 21:997-1004. [PMID: 37147885 DOI: 10.1002/msc.1773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/21/2023] [Accepted: 04/22/2023] [Indexed: 05/07/2023]
Abstract
INTRODUCTION We aimed to screen the presence of silent myocardial ischaemia, in established rheumatoid arthritis (RA) patients, using a stress test then to evaluate its association with the disease activity and the cardiovascular (CV) risk factors and Heartscore. METHODS It is a transversal study in a rheumatologic centre in Tunisia. One hundred three RA patients, asymptomatic for CV diseases, were submitted to a stress test. Demographic data, CV risk factors and disease characteristics were assessed and risk factors of silent myocardial ischaemia in RA patients were identified. RESULTS There were 103 patients (sex-ratio = 0.3) with a mean age of 53 ± 10 years. The evaluation of the disease activity showed that the mean Disease Activity Score in 28 joints C-reactive protein, Clinical Disease Activity Index and Simplified Disease Activity Index were 3.9 ± 1.38, 17.17 ± 11.4 and 33.39 ± 26, respectively. The ischaemic ratio (CT/HDL) revealed that 42% of patients had a moderate to high myocardial ischaemic risk. HeartSCORE was high in 35% of cases. A silent myocardial ischaemia in the stress test was found in 11 patients (10.6%) and was associated with male sex (p = 0.03), advanced age (p = 0.04), erosive character (p = 0.05), the advanced age of the RA diagnosis (p = 0.01) and the ischaemic ratio (p = 0.05). No relationship was found with the majority of traditional CV risk factors nor with disease activity variables. CONCLUSION Our results corroborated the hypothesis that the stress test could reveal subclinical CV dysfunction and supported the utility of the Heartscore as a screening tool.
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Affiliation(s)
- Leila Rouached
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Rawdha Tekaya
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Hiba Ben Ayed
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Selma Bouden
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Aicha Ben Tekaya
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Habib Ben Ahmed
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
- Department of Cardiology, Charles Nicolle Hospital, Tunis, Tunisia
| | - Ines Mahmoud
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Olfa Saidane
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
| | - Leila Abdelmoula
- Department of Rheumatology, Charles Nicolle Hospital, Tunis, Tunisia
- Faculty of Medicine of Tunis, Tunis El Manar University, Tunis, Tunisia
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Mezzetti E, Costantino A, Leoni M, Pieretti R, Di Paolo M, Frati P, Maiese A, Fineschi V. Autoimmune Heart Disease: A Comprehensive Summary for Forensic Practice. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1364. [PMID: 37629654 PMCID: PMC10456745 DOI: 10.3390/medicina59081364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/05/2023] [Accepted: 07/20/2023] [Indexed: 08/27/2023]
Abstract
Autoimmune heart disease is a non-random condition characterised by immune system-mediated aggression against cardiac tissue. Cardiac changes often exhibit nonspecific features and, if unrecognised, can result in fatal outcomes even among seemingly healthy young individuals. In the absence of reliable medical history, the primary challenge lies in differentiating between the various cardiopathies. Numerous immunohistochemical and genetic studies have endeavoured to characterise distinct types of cardiopathies, facilitating their differentiation during autopsy examinations. However, the presence of a standardised protocol that forensic pathologists can employ to guide their investigations would be beneficial. Hence, this summary aims to present the spectrum of autoimmune cardiopathies, including emerging insights such as SARS-CoV-2-induced cardiopathies, and proposes the utilisation of practical tools, such as blood markers, to aid forensic pathologists in their routine practice.
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Affiliation(s)
- Eleonora Mezzetti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Andrea Costantino
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Matteo Leoni
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Rebecca Pieretti
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Marco Di Paolo
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (P.F.); (V.F.)
| | - Aniello Maiese
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, Institute of Legal Medicine, University of Pisa, 56126 Pisa, Italy; (E.M.); (A.C.); (M.L.); (R.P.); (M.D.P.)
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedical Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy; (P.F.); (V.F.)
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Pan SY, Tian HM, Zhu Y, Gu WJ, Zou H, Wu XQ, Cheng RJ, Yang Z. Cardiac damage in autoimmune diseases: Target organ involvement that cannot be ignored. Front Immunol 2022; 13:1056400. [PMID: 36483559 PMCID: PMC9722763 DOI: 10.3389/fimmu.2022.1056400] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 11/07/2022] [Indexed: 11/23/2022] Open
Abstract
Autoimmune diseases are diseases that cause damage to the body's own tissues as a result of immune dysfunction, often involving multiple organs and systems. The heart is one of the common target organs of autoimmune diseases. The whole structure of the heart can be affected, causing microcirculatory disorders, arrhythmias, pericardial damage, myocarditis, myocardial fibrosis, and impaired valvular function. However, early clinical manifestations of autoimmune heart damage are often overlooked because they are insidious or have no typical features. The damage is often severe and irreversible when symptoms are apparent, even life-threatening. Therefore, early detection and treatment of heart damage in autoimmune diseases is particularly important. Herein, we review the clinical features and mechanisms of cardiac damage in common rheumatic diseases.
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Affiliation(s)
- Shu-Yue Pan
- Department of Rheumatology and Immunology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
| | - Hui-Min Tian
- Department of Rheumatology and Immunology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
| | - Yong Zhu
- Department of Rheumatology and Immunology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
| | - Wei-Jie Gu
- Department of Rheumatology and Immunology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
| | - Hao Zou
- Department of Rheumatology and Immunology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
| | - Xu-Qiang Wu
- Department of Rheumatology and Immunology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
| | - Rui-Juan Cheng
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Zhi Yang
- Department of Radiology, The Fifth People’s Hospital Affiliated to Chengdu University of Traditional Chinese Medicine/Chengdu Fifth People’s Hospital, Chengdu, China
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Sierra-Galan LM, Bhatia M, Alberto-Delgado AL, Madrazo-Shiordia J, Salcido C, Santoyo B, Martinez E, Soto ME. Cardiac Magnetic Resonance in Rheumatology to Detect Cardiac Involvement Since Early and Pre-clinical Stages of the Autoimmune Diseases: A Narrative Review. Front Cardiovasc Med 2022; 9:870200. [PMID: 35911548 PMCID: PMC9326004 DOI: 10.3389/fcvm.2022.870200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Autoimmune diseases (ADs) encompass multisystem disorders, and cardiovascular involvement is a well-known feature of autoimmune and inflammatory rheumatic conditions. Unfortunately, subclinical and early cardiovascular involvement remains clinically silent and often undetected, despite its well-documented impact on patient management and prognostication with an even more significant effect on severe and future MACE events as the disease progresses. Cardiac magnetic resonance imaging (MRI), today, commands a unique position of supremacy versus its competition in cardiac assessment and is the gold standard for the non-invasive evaluation of cardiac function, structure, morphology, tissue characterization, and flow with the capability of evaluating biventricular function; myocardium for edema, ischemia, fibrosis, infarction; valves for thickening, large masses; pericardial inflammation, pericardial effusions, and tamponade; cardiac cavities for thrombosis; conduction related abnormalities and features of microvascular and large vessel involvement. As precise and early detection of cardiovascular involvement plays a critical role in improving the outcome of rheumatic and autoimmune conditions, our review aims to highlight the evolving role of CMR in systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), rheumatoid arthritis (RA), systemic sclerosis (SSc), limited sclerosis (LSc), adult-onset Still's disease (AOSD), polymyositis (PM), dermatomyositis (DM), eosinophilic granulomatosis with polyangiitis (EGPA) (formerly Churg-Strauss syndrome), and DRESS syndrome (DS). It draws attention to the need for concerted, systematic global interdisciplinary research to improve future outcomes in autoimmune-related rheumatic conditions with multiorgan, multisystem, and cardiovascular involvement.
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Affiliation(s)
- Lilia M. Sierra-Galan
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Mona Bhatia
- Department of Imaging, Fortis Escorts Heart Institute, New Delhi, India
| | | | - Javier Madrazo-Shiordia
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Carlos Salcido
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Bernardo Santoyo
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Eduardo Martinez
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
| | - Maria Elena Soto
- Cardiology Department of the Cardiovascular Division of the American British Cowdray Medical Center, Mexico City, Mexico
- Immunology Department of the National Institute of Cardiology, “Ignacio Chavez”, Mexico City, Mexico
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Dubiel-Braszczok B, Nowak K, Owczarek A, Engelmann M, Gumkowska-Sroka O, Kotyla PJ. Differential impact of biologic therapy on heart function biomarkers in rheumatoid arthritis patients: Observational study on etanercept, adalimumab and tocilizumab. Curr Pharm Des 2022; 28:2029-2037. [PMID: 35638285 DOI: 10.2174/1381612828666220527141532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/30/2022] [Indexed: 11/22/2022]
Abstract
Background Rheumatoid arthritis (RA) represents the most frequent form of inflammatory arthritis affecting approximately 1% of the population worldwide. Introduction of novel therapeutic strategies targeting proinflammatory cytokines (TNF-α and interleukin-6) revolutionized the treatment of RA. This kind of treatment, although effective in a substantial portion of patients, may potentially cause many side effects. Among them cardiovascular safety is one of the main concerns. Objectives In the present study, we investigated what impact treatment with anti-TNF-α and anti-IL-6 agents may have on heart function and levels of heart function biomarkers Methods To measure this, we used cardiac function biomarkers such as NT-pro Brain Natriuretic Peptide, mid regional pro Atrial Natriuretic Peptide, Galectin-3 and Heart-Type Fatty Acid-Binding Protein and compared them to patients treated with methotrexate as well as healthy controls. Results Patients treated with biologics were characterized by low disease activity or were in remission. The disease activity in these groups were significantly lower in comparison to the methotrexate group. All patient recruited to the study were characterized by normal heart function measured with the use of echocardiography (EF>50%). With the exception of MR-proANP between tocilizumab and adalimumab (median: 1.01 vs 0.49 nmol/L, p < 0.05), we failed to observe any significant differences in biomarkers levels between groups treated with biologics. Contrary to this, patients on MTX showed higher NT-proBNP levels compared to adalimumab, and healthy controls (p < 0.05 for both). Striking differences have been shown in regard to H-FABP. The levels of these biomarkers were elevated in all biologics and the methotrexate group as compared to healthy controls. Conclusion As this biomarker reflects potential heart injury we suggest that heart damage proceeds in continuous manner in RA patients despite effective treatment and attainment of remission/low disease activity. This finding however should be verify in larger cohort of RA patients to ascertain if routine assessment of H-FABP may be useful for detection of patients with RA who are at risk of development of heart damage.
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Affiliation(s)
- Beata Dubiel-Braszczok
- Department of Internal Medicine, Rheumatology and Clinical Immunology Faculty of Medicine in Katowice Medical University of Silesia, Katowice, Poland
| | - Karolina Nowak
- Department of Internal Medicine, Rheumatology and Clinical Immunology Faculty of Medicine in Katowice Medical University of Silesia, Katowice, Poland
| | - Aleksander Owczarek
- Department of Pathophysiology, Health Promotion and Obesity Management Unit Faculty of Medicine in Katowice Medical University of Silesia, Katowice, Poland
| | - Małgorzata Engelmann
- Department of Physiotherapy in Internal Medicine Academy of Physical Education in Katowice, Poland
| | | | - Przemysław J Kotyla
- Department of Internal Medicine, Rheumatology and Clinical Immunology Faculty of Medicine in Katowice Medical University of Silesia, Katowice, Poland
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Kumar K, Seetharam K, Poonam F, Gulati A, Sadiq A, Shetty V. The Role of Cardiac Imaging in the Evaluation of Cardiac Involvement in Systemic Diseases. Cureus 2021; 13:e20708. [PMID: 35106243 PMCID: PMC8788898 DOI: 10.7759/cureus.20708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/23/2021] [Indexed: 11/05/2022] Open
Abstract
For systemic diseases like rheumatoid arthritis, systemic lupus erythematosus (SLE), systemic sclerosis, systemic vasculitis, myopathies, and mixed connective tissue diseases, cardiac disease is a major contributing factor for morbidity and mortality. The cardiovascular manifestations are the result of various pathophysiological components, which complicate management. Furthermore, the signs and symptoms can be subtle and missed due to the complex nature of the underlying condition. As a result, various imaging approaches play an imperative role in diagnosis and prognosis. The evolving role of these modalities could lead to risk stratification and improved therapies in the future. In conclusion, our review article will highlight the role of cardiac imaging in the evaluation of cardiac involvement for systemic diseases.
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Early Myocardial Changes in Patients with Rheumatoid Arthritis without Known Cardiovascular Diseases-A Comprehensive Cardiac Magnetic Resonance Study. Diagnostics (Basel) 2021; 11:diagnostics11122290. [PMID: 34943529 PMCID: PMC8699890 DOI: 10.3390/diagnostics11122290] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 11/30/2021] [Accepted: 12/06/2021] [Indexed: 01/16/2023] Open
Abstract
Clinically silent cardiac disease is frequently observed in rheumatoid arthritis (RA), and cardiovascular complications are the leading cause of mortality in RA. We sought to evaluate the myocardium of young RA patients without known cardiac disease using cardiac magnetic resonance (CMR), including T1/T2 mapping sequences. Eighteen RA patients (median age 41 years, 83% females) mainly with low disease activity or in remission and without any known cardiovascular disease were prospectively included to undergo CMR. A control group consisted of 10 sex- and age-matched patients without RA or any known structural cardiovascular disease. Heart chambers size and left/right ventricular systolic function were similar in patients with RA and controls. Signs of myocardial oedema were present in up to 39% of RA patients, including T2 time above cut-off value in 7 patients (39%) in comparison to none of the controls (p = 0.003) and T2 signal intensity ratio above the cut-off value in 6 patients (33%) and in none of the controls (p = 0.06). Extracellular volume was similar in both groups signifying a lack of diffuse fibrosis in studied group of RA patients. There were also no signs of late gadolinium enhancement (LGE) in either group except for one patient with RA who was found to have prior silent myocardial infarction. No correlation was found between markers of disease severity and markers of oedema observed on CMR in patients with RA. Nevertheless, patients with increased T2 time (≥50 ms) were more likely to have X-ray erosions (p = 0.02) and a longer duration between symptom onset and diagnosis (p = 0.02). Finally, there were no significant arrhythmias on 24-h ECG Holter monitoring in RA patients. CMR features of myocardial oedema without signs of myocardial fibrosis were found in 39% of young RA patients without known heart disease or cardiac symptoms. Presence of myocardial oedema was associated with X-ray erosions and a longer duration between symptom onset and diagnosis. The clinical significance of the observed early myocardial changes accompanying RA requires additional studies.
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Rezuș E, Macovei LA, Burlui AM, Cardoneanu A, Rezuș C. Ischemic Heart Disease and Rheumatoid Arthritis-Two Conditions, the Same Background. Life (Basel) 2021; 11:life11101042. [PMID: 34685413 PMCID: PMC8537055 DOI: 10.3390/life11101042] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2021] [Revised: 09/30/2021] [Accepted: 10/01/2021] [Indexed: 12/20/2022] Open
Abstract
Rheumatoid arthritis (RA) is one of the most frequent inflammatory rheumatic diseases, having a considerably increased prevalence of mortality and morbidity due to cardiovascular disease (CVD). RA patients have an augmented risk for ischemic and non-ischemic heart disease. Increased cardiovascular (CV) risk is related to disease activity and chronic inflammation. Traditional risk factors and RA-related characteristics participate in vascular involvement, inducing subclinical changes in coronary microcirculation. RA is considered an independent risk factor for coronary artery disease (CAD). Endothelial dysfunction is a precocious marker of atherosclerosis (ATS). Pro-inflammatory cytokines (such as TNFα, IL-1, and IL-6) play an important role in synovial inflammation and ATS progression. Therefore, targeting inflammation is essential to controlling RA and preventing CVD. Present guidelines emphasize the importance of disease control, but studies show that RA- treatment has a different influence on CV risk. Based on the excessive risk for CV events in RA, permanent evaluation of CVD in these patients is critical. CVD risk calculators, designed for the general population, do not use RA-related predictive determinants; also, new scores that take into account RA-derived factors have restricted validity, with none of them encompassing imaging modalities or specific biomarkers involved in RA activity.
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Affiliation(s)
- Elena Rezuș
- Department of Rheumatology and Rehabilitation, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania; (E.R.); (A.M.B.); (A.C.)
| | - Luana Andreea Macovei
- Department of Rheumatology and Rehabilitation, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania; (E.R.); (A.M.B.); (A.C.)
- Correspondence:
| | - Alexandra Maria Burlui
- Department of Rheumatology and Rehabilitation, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania; (E.R.); (A.M.B.); (A.C.)
| | - Anca Cardoneanu
- Department of Rheumatology and Rehabilitation, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania; (E.R.); (A.M.B.); (A.C.)
| | - Ciprian Rezuș
- Department of Internal Medicine, Grigore T. Popa University of Medicine and Pharmacy, 700115 Iași, Romania;
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Błyszczuk P, Szekanecz Z. Pathogenesis of ischaemic and non-ischaemic heart diseases in rheumatoid arthritis. RMD Open 2021; 6:rmdopen-2019-001032. [PMID: 31958278 PMCID: PMC7046979 DOI: 10.1136/rmdopen-2019-001032] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 11/17/2019] [Accepted: 11/22/2019] [Indexed: 12/11/2022] Open
Abstract
Rheumatoid arthritis (RA) is characterised by a chronic inflammatory condition of the joints, but the comorbidities of RA predominantly contribute to the reduced lifespan associated with this disease. Clinical data indicate that cardiovascular disease is the major comorbidity associated with mortality in RA. In this review, we aimed to describe the pathogenesis of heart failure in RA. First, we emphasised the fundamental differences between ischaemic and non-ischaemic heart diseases and referred to their relevance in excessive cardiovascular-dependent mortality in RA. Second, we highlighted aspects of asymptomatic changes in cardiac tissue and in coronary blood vessels that are commonly found in patients with diagnosed RA. Third, we focused on high-grade systemic inflammation as a key trigger of ischaemic and non-ischaemic heart diseases in RA, and described the implication of conventional and biologic antirheumatic medications on the development and progression of heart disease. In particular, we discussed the roles of tumour necrosis factor-alpha (TNF-α) and anti-TNF-α therapies on the development and progression of ischaemic and non-ischaemic heart diseases in RA.
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Affiliation(s)
- Przemysław Błyszczuk
- Center of Experimental Rheumatology, University of Zurich, Schlieren, Switzerland .,Department of Clinical Immunology, Jagiellonian University Medical College, Cracow, Poland
| | - Zoltan Szekanecz
- Department of Rheumatology, University of Debrecen, Faculty of Medicine, Debrecen, Hungary
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Cioffi G, Viapiana O, Orsolini G, Ognibeni Sonographer F, Dalbeni A, Gatti D, Adami G, Fassio A, Rossini M, Giollo A. Left ventricular hypertrophy predicts poorer cardiovascular outcome in normotensive normoglycemic patients with rheumatoid arthritis. Int J Rheum Dis 2021; 24:510-518. [PMID: 33719195 DOI: 10.1111/1756-185x.14082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Patients with rheumatoid arthritis (RA) develop early changes in left ventricular (LV) geometry and experience cardiovascular events in excess than in the general population. This study was designed to assess prevalence, predictors and prognostic role of LV hypertrophy (LVH) in a selected group of RA patients with normal blood pressure and glycemia who should be at low risk for LVH. METHODS We prospectively analyzed 241 normotensive normoglycemic RA patients (mean age 53 ± 12 years, 61% women) involved in a primary prevention program for cardiovascular diseases who were followed-up for 40 (24-56) months. LVH was detected by echocardiography and defined as LV mass ≥49.2 g/m2.7 for men and ≥46.7 g/m2.7 for women. Primary outcome was a composite of cardiovascular death/hospitalization. RESULTS LVH was detected in 39 patients (16%). Older age (>53 years), greater body mass index (BMI > 25 kg/m2 ), longer duration of RA disease, anti-cyclic citrullinated peptide antibody (ACPA) positivity and concentric LV geometry were the variables associated with LVH. During the follow-up, a cardiovascular event occurred in 12 of 39 (31%) patients with LVH and in 22 of 202 (11%; P < .001) patients without LVH. LVH independently predicted cardiovascular events (hazards ratio 3.28 [95% CI 1.03-9.20], P = .03) at Cox regression analysis together with C-reactive protein and ACPA positivity. CONCLUSIONS Nearly one-sixth of normotensive normoglycemic RA patients analyzed in a primary prevention program for cardiovascular diseases has LVH which is associated with obesity and older age, and strongly predicts cardiovascular event in these subjects.
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Affiliation(s)
- Giovanni Cioffi
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy.,Division of Cardiac Rehabilitation, S. Pancrazio Hospital, Trento, Italy
| | - Ombretta Viapiana
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Orsolini
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | | | - Andrea Dalbeni
- Department of Medicine, General Medicine and Hypertension and Liver Unit, University of Verona & Azienda Ospedaliera Universitaria Integrata of Verona, Verona, Italy
| | - Davide Gatti
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Giovanni Adami
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Angelo Fassio
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Maurizio Rossini
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
| | - Alessandro Giollo
- Rheumatology Section, Department of Medicine, University of Verona, Verona, Italy
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Figus FA, Piga M, Azzolin I, McConnell R, Iagnocco A. Rheumatoid arthritis: Extra-articular manifestations and comorbidities. Autoimmun Rev 2021; 20:102776. [PMID: 33609792 DOI: 10.1016/j.autrev.2021.102776] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 12/27/2020] [Indexed: 12/20/2022]
Abstract
Although synovitis is the pathological hallmark of rheumatoid arthritis (RA), many extra-articular manifestations (EMs) and comorbidities likely occur due to the complex, chronic, inflammatory, and autoimmune features of RA. Cardiovascular (CV) disease is the most common cause of death in patients with RA. Compared to the general population, patients with RA have twice the risk of myocardial infarction and up to 50% increased CV mortality risk. Severe and prolonged disease activity, genetics, and inflammation (e.g. CRP, ACPA, cytokines, matrix-degrading enzymes) play important roles in CV disease and atheroscleroticdamage. The second major cause of death in patients with RA is respiratory disease, which occurs in 30-40% of patients. RA may affect the lung interstitium, airways, and pleurae, while pulmonary vascular involvement is less frequent. Central and peripheral nervous system involvement is usually due to small vessel vasculitis, joint damage, or drug toxicity. There is also evidence that microvascular cerebral damage caused by systemic inflammation is associated with the development of Alzheimer's disease and vascular dementia. Some observational studies have hinted how Disease Modified Anti-Rheumatic Drugs and biologics could reduce the incidence of dementia. Primary gastrointestinal and renal involvements are rare and often relate to drug therapy. To minimize morbidity and mortality, physicians must manage RA disease activity (treat-to-target) and monitor risk factors and concomitant conditions (e.g. smoking cessation; weight regulation; monitoring blood pressure, lipids, thyroid hormone, folic acid and homocysteine; screening for depression, anxiety, atlantoaxial instability, and atherosclerosis). This article aims to provide an overview of the most prevalent and important EMs and comorbidities associated with RA.
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Affiliation(s)
- Fabiana Assunta Figus
- Academic Rheumatology Centre, MFRU and Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Torino, Italy
| | - Matteo Piga
- Rheumatology Unit, University Clinic and AOU of Cagliari, Monserrato, Italy
| | - Irene Azzolin
- Academic Rheumatology Centre, MFRU and Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Torino, Italy
| | | | - Annamaria Iagnocco
- Academic Rheumatology Centre, MFRU and Dipartimento Scienze Cliniche e Biologiche, Università degli Studi di Torino, Torino, Italy.
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12
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Wang Z, Kun Y, Lei Z, Dawei W, Lin P, Jibo W. LncRNA MIAT downregulates IL-1β, TNF-ɑ to suppress macrophage inflammation but is suppressed by ATP-induced NLRP3 inflammasome activation. Cell Cycle 2021; 20:194-203. [PMID: 33459112 DOI: 10.1080/15384101.2020.1867788] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Cardiovascular disease (CVD) has been identified as the leading cause of premature deaths in rheumatoid arthritis (RA), accounting for about 40 to 50% of all deaths. Macrophage inflammation is regarded as a key point to link to the two diseases. Recently, long non-coding RNAs (lncRNAs) have acknowledged as a regulator of inflammation significantly. Here, we firstly found that lncRNA myocardial infarction associated transcript (lncRNA MIAT), a crucial lncRNA to regulate CVD, expressed increasingly in synovium and myocardial tissues of collagen-induced arthritis (CIA) mice. Besides, we also verified that the increased infiltration of macrophage occurred in those tissues of the CIA. In vitro, we found that macrophage inflammation induced by LPS could up-regulate lncRNA MIAT expression. LncRNA MIAT seemed to inhibit the expression of IL-1β, TNF-ɑ and be suppressed by ATP-induced NLRP3 inflammasome activation pathway. Therefore, these data indicated an anti-inflammatory effect of lncRNA MIAT in macrophage and an original research direction for high cardiovascular risk in RA.
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Affiliation(s)
- Ziye Wang
- Department of Rheumatology & Clinical Immunology, Affiliated Hospital of Qingdao University , Qingdao,China
| | - Yang Kun
- Medical Research Center, Affiliated Hospital of Qingdao University , China
| | - Zhao Lei
- Department of Rheumatology & Clinical Immunology, Affiliated Hospital of Qingdao University , Qingdao,China
| | - Wen Dawei
- Department of Rheumatology & Clinical Immunology, Affiliated Hospital of Qingdao University , Qingdao,China
| | - Pan Lin
- Department of Rheumatology & Clinical Immunology, Affiliated Hospital of Qingdao University , Qingdao,China
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13
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Groner LK, Green DB, Weisman SV, Legasto AC, Toy D, Gruden JF, Escalon JG. Thoracic Manifestations of Rheumatoid Arthritis. Radiographics 2021; 41:32-55. [PMID: 33411607 DOI: 10.1148/rg.2021200091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Rheumatoid arthritis (RA) is one of the most common chronic systemic inflammatory diseases and the most common chronic inflammatory arthritis. Classically a progressive symmetric polyarthritis, RA is characterized by inflammation, erosions, bone loss, and joint destruction. Up to half of patients with RA exhibit extra-articular manifestations (EAMs), which may precede articular disease and are more common in patients with seropositive RA (patients with detectable serum levels of rheumatoid factor and/or anticitrullinated peptide antibodies). Cardiovascular and pulmonary EAMs are the largest contributors to morbidity and mortality in RA and may be especially devastating. Imaging has a significant role in diagnosing these EAMs and assessing response to treatment. Although treatment with disease-modifying antirheumatic drugs has redefined the natural history of RA and helped many patients achieve low disease activity, patients are at risk for treatment-related complications, as well as infections. The clinical features of drug-induced lung disease and infection can overlap considerably with those of EAMs, presenting a diagnostic challenge. Radiologists, by recognizing the imaging characteristics and evolution of these various processes, are essential in diagnosing and distinguishing among EAMs, treatment-related complications, and unrelated processes and formulating an appropriate differential diagnosis. Moreover, recognizing these disease processes at imaging and contextualizing imaging findings with clinical information and laboratory and pathologic findings can facilitate definitive diagnosis and proper treatment. The authors review the articular and extra-articular thoracic imaging manifestations of RA, including cardiovascular, respiratory, and pleural diseases, as well as treatment-related complications and common infections. ©RSNA, 2021.
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Affiliation(s)
- Lauren K Groner
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
| | - Daniel B Green
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
| | - Stacey V Weisman
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
| | - Alan C Legasto
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
| | - Dennis Toy
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
| | - James F Gruden
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
| | - Joanna G Escalon
- From the Department of Radiology, New York-Presbyterian Hospital-Weill Cornell Medical Center, 525 E 68th St, New York, NY 10065
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Ingegnoli F, Buoli M, Antonucci F, Coletto LA, Esposito CM, Caporali R. The Link Between Autonomic Nervous System and Rheumatoid Arthritis: From Bench to Bedside. Front Med (Lausanne) 2020; 7:589079. [PMID: 33365319 PMCID: PMC7750536 DOI: 10.3389/fmed.2020.589079] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/30/2020] [Indexed: 12/25/2022] Open
Abstract
Neuronal stimulation is an emerging field of research focused on the management and treatment of various diseases through the reestablishment of physiological homeostasis. Electrical vagus nerve stimulation has recently been proposed as a revolutionary therapeutic option for rheumatoid arthritis (RA) in combination with or even as a replacement for conventional and biological drugs. In the past few years, disruption of the autonomic system has been linked to RA onset and activity. Novel research on the link between the autonomic nervous system and the immune system (immune-autonomics) has paved the way for the development of innovative RA management strategies. Clinical evidence supports this approach. Cardiovascular involvement, in terms of reduced baroreflex sensitivity and heart rate variability-derived indices, and mood disorders, common comorbidities in patients with RA, have been linked to autonomic nervous system dysfunction, which in turn is influenced by increased levels of circulating pro-inflammatory cytokines. This narrative review provides an overview of the autonomic nervous system and RA connection, discussing most of the common cardiac and mental health-related RA comorbidities and their potential relationships to systemic and joint inflammation.
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Affiliation(s)
- Francesca Ingegnoli
- Division of Clinical Rheumatology, Gaetano Pini Hospital, Milan, Italy.,Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - Massimiliano Buoli
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Flavia Antonucci
- Department of Medical Biotechnology and Translational Medicine (BIOMETRA), Università degli Studi di Milano, Milan, Italy
| | - Lavinia Agra Coletto
- Division of Clinical Rheumatology, Gaetano Pini Hospital, Milan, Italy.,Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
| | - Cecilia Maria Esposito
- Department of Neurosciences and Mental Health, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Ca'Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
| | - Roberto Caporali
- Division of Clinical Rheumatology, Gaetano Pini Hospital, Milan, Italy.,Department of Clinical Sciences and Community Health, Research Center for Adult and Pediatric Rheumatic Diseases, Università degli Studi di Milano, Milan, Italy
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15
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Sidiropoulos P, Sfikakis PP, Boumpas DD, Vassilopoulos D. Twenty Years of Targeted Treatment in Rheumatoid Arthritis in the Greek Databases: Achievements and Unmet Needs. Mediterr J Rheumatol 2019; 30:141-146. [PMID: 32185356 PMCID: PMC7045862 DOI: 10.31138/mjr.30.3.141] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 06/05/2019] [Accepted: 06/22/2019] [Indexed: 11/25/2022] Open
Abstract
Rheumatoid arthritis (RA) is a chronic autoimmune disease associated with substantial morbidity and mortality especially in difficult to treat cases. Biologic agents were introduced 20 years ago in Greece and RA management has paralleled the European experience. Several publications from the country have captured important aspects of the disease from its epidemiology to the clinical use of biologics and management of comorbidities. In this communication we review the management of RA and its evolution over the last 20 years in Greece, discussing the major achievements and the unmet needs of the disease in an effort to put this into a perspective. We conclude that introduction of biologic therapy has substantially changed the treatment of difficult to treat rheumatoid arthritis in-spite of the multiple unmet needs. While striving for even better outcomes, we cannot lose sight of the major impact of biologic therapies on the lives of patients with rheumatoid arthritis.
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Affiliation(s)
- Prodromos Sidiropoulos
- Department of Rheumatology and Clinical Immunology, School of Medicine, University of Crete, Greece
- Laboratory of Rheumatology, Inflammation and Autoimmunity, Institute of Molecular Biology and Biotechnology, Foundation for Research and Technology, Heraklion, Greece
| | - Petros P. Sfikakis
- First Department of Propaedeutic and Internal Medicine & Rheumatology Unit, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Joint Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
| | - Dimitrios D. Boumpas
- 4th Department of Internal Medicine, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
- Joint Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
- Laboratory of Immune Regulation and Tolerance, Autoimmunity and Inflammation, Biomedical Research Foundation of the Academy of Athens, Athens, Greece
| | - Dimitrios Vassilopoulos
- 2nd Department of Medicine and Laboratory, Hippokration General Hospital, Medical School, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
- Joint Rheumatology Program, National and Kapodistrian University of Athens, School of Medicine, Athens, Greece
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16
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Mavrogeni SI. "The discreet charm" of cardiovascular disease in Rheumatoid arthritis. Hellenic J Cardiol 2019; 60:36-37. [PMID: 30639353 DOI: 10.1016/j.hjc.2019.01.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/19/2018] [Accepted: 01/03/2019] [Indexed: 10/27/2022] Open
Affiliation(s)
- Sophie I Mavrogeni
- Onassis Cardiac Surgery Center and Kapodistrian University of Athens, Athens, Greece.
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17
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Sarajlic P, Fridén C, Lund LH, Manouras A, Venkateshvaran A, Larsson SC, Nordgren B, Opava CH, Lundberg IE, Bäck M. Enhanced ventricular-arterial coupling during a 2-year physical activity programme in patients with rheumatoid arthritis: a prospective substudy of the physical activity in rheumatoid arthritis 2010 trial. J Intern Med 2018; 284:664-673. [PMID: 29143384 DOI: 10.1111/joim.12715] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To establish how guided physical activity in patients with rheumatoid arthritis (RA) without known cardiovascular disease affected vascular and cardiac function, and how these two entities were prospectively interconnected in this patient group. METHODS Prospective substudy of 29 participants in the Physical Activity in RA (PARA) 2010 trial. All subjects were examined at baseline, at year 1 and 2 with measures of pulse wave velocity and arterial augmentation index, as well as echocardiographic evaluation of diastolic parameters and ventricular-arterial coupling. Muscle strength and aerobic exercise capacity were assessed at baseline and yearly. All participants performed physiotherapist-guided aerobic and muscle strength exercise during 2 years and were reminded through SMS to report physical activity progress. RESULTS This cohort of patients with RA exhibited increased vascular stiffness despite normal blood pressure. At baseline, lower muscle strength was associated with increased vascular stiffness (β = 0.68; P = 0.004), whereas lower aerobic working capacity was associated with left ventricular diastolic dysfunction (β = 0.85; P = 0.03). There was a significant positive correlation between vascular stiffness and diastolic dysfunction at baseline (R2 = 0.64) and for the changes in those parameters observed during 2 years of guided physical activity. Finally, a significant improvement in ventricular-arterial coupling was observed after exercise (P < 0.001). CONCLUSION These results indicate that although differentially associated with physical capacity parameters, improved vascular stiffness and improved diastolic dysfunction are interrelated, and that an optimization of the ventricular-arterial coupling may contribute to the beneficial effects of physical activity in patients with RA.
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Affiliation(s)
- P Sarajlic
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - C Fridén
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - L H Lund
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Heart and Vascular Theme Division of Heart Failure, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Manouras
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Heart and Vascular Theme Division of Heart Failure, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - A Venkateshvaran
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Heart and Vascular Theme Division of Heart Failure, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - S C Larsson
- Institute of Environmental Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - B Nordgren
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - C H Opava
- Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - I E Lundberg
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Rheumatology Unit, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - M Bäck
- Department of Medicine Solna, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.,Heart and Vascular Theme Division of Valvular and Coronary Disease, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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18
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Lehmonen L, Vuorinen AM, Koivuniemi R, Leirisalo-Repo M, Holmström M, Kivistö S, Kaasalainen T. One-Year Follow-up Study Detects Myocardial Changes with Cardiovascular Magnetic Resonance Tagging in Active Rheumatoid Arthritis. Acad Radiol 2018; 25:476-485. [PMID: 29199058 DOI: 10.1016/j.acra.2017.10.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 10/23/2017] [Accepted: 10/24/2017] [Indexed: 02/02/2023]
Abstract
RATIONALE AND OBJECTIVES To evaluate the effects of 1 year of medical treatment on myocardial function in active rheumatoid arthritis (RA). MATERIALS AND METHODS Thirty-nine female patients with RA without any known cardiovascular disease underwent a cardiovascular magnetic resonance (CMR) examination before and after 1 year of antirheumatic treatment. The population comprised untreated active early RA (ERA) and chronic RA patients, who were grouped accordingly. The CMR protocol included volumetric determinations, late gadolinium enhancement imaging, myocardial tagging, and native T1 mapping. DAS28-CRP disease activity scores were calculated before and after the treatment. RESULTS Results are reported as median (quartile 1-quartile 3). Time to peak diastolic filling rate improved in ERA (495 [443-561] ms vs 441 [340-518] ms, P = .018). Peak diastolic mean mid short-axis circumferential strain rate of all six segments was improved (82 [74-91] %/s vs 91 [77-100] %/s, P = .05), particularly in the anterior segment (82 [63-98] %/s vs 86 [77-109] %/s, P = .013). DAS28-CRP decreased in ERA (3.8 [3.2-4.1] vs 1.6 [1.4-2.2], P < .001). In chronic RA, no statistically significant improvement was detected. CONCLUSIONS Early treatment of active RA is important, as myocardial function detected with CMR tagging improved in ERA in parallel with decreasing inflammatory activity.
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19
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Comarmond C, Cacoub P. Myocarditis in auto-immune or auto-inflammatory diseases. Autoimmun Rev 2017; 16:811-816. [PMID: 28572050 DOI: 10.1016/j.autrev.2017.05.021] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 04/22/2017] [Indexed: 12/12/2022]
Abstract
Myocarditis is a major cause of heart disease in young patients and a common precursor of heart failure due to dilated cardiomyopathy. Some auto-immune and/or auto-inflammatory diseases may be accompanied by myocarditis, such as sarcoidosis, Behçet's disease, eosinophilic granulomatosis with polyangiitis, myositis, and systemic lupus erythematosus. However, data concerning myocarditis in such auto-immune and/or auto-inflammatory diseases are sparse. New therapeutic strategies should better target the modulation of the immune system, depending on the phase of the disease and the type of underlying auto-immune and/or auto-inflammatory disease.
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Affiliation(s)
- Cloé Comarmond
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Département Hospitalo-Universitaire I2B, UPMC Univ Paris 06, F-75013 Paris, France; INSERM, UMR 7211, F-75005 Paris, France; CNRS, UMR 7211, F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France
| | - Patrice Cacoub
- Département de Médecine Interne et Immunologie Clinique, Assistance Publique-Hôpitaux de Paris (AP-HP), Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France; Département Hospitalo-Universitaire I2B, UPMC Univ Paris 06, F-75013 Paris, France; INSERM, UMR 7211, F-75005 Paris, France; CNRS, UMR 7211, F-75005 Paris, France; INSERM, UMR_S 959, F-75013 Paris, France.
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20
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Myocardial Perfusion in Rheumatoid Arthritis Patients: Associations with Traditional Risk Factors and Novel Biomarkers. BIOMED RESEARCH INTERNATIONAL 2017; 2017:6509754. [PMID: 28553649 PMCID: PMC5434312 DOI: 10.1155/2017/6509754] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 04/02/2017] [Indexed: 12/16/2022]
Abstract
Introduction. Cardiovascular (CV) diseases are a major cause of death in rheumatoid arthritis (RA) patients. Novel biomarkers [B-type natriuretic peptide (BNP); osteoprotegerin (OPG)/receptor activator of nuclear factor-kappa B ligand (RANKL) ratio; and dickkopf-1 (DKK-1)] have been used in CV risk assessment. We analysed, in established RA patients, the presence of silent myocardial ischemia and its association with clinical variables, BNP, and bone and atheroma biomarkers. Methods. From a single-center tertiary referral hospital, RA patients asymptomatic for CV disease were submitted to myocardial perfusion scintigraphy (MPS) under adenosine stress and biomarkers measurements. Logistic regression was used to estimate crude odds ratios (OR) and 95% confidence intervals (CI). Results. In 189 patients, perfusion defects were frequent (25%) and associated with BNP ≥ 100 pg/mL (OR = 5.68; 95% CI: 2.038–15.830), fourth log OPG/RANKL ratio quartile (OR = 2.88; 95% CI: 1.091–7.622), and DKK-1 ≥ 133 pmol/L (OR = 2.69; 95% CI: 1.058–6.840). Similar associations were confirmed in those with C-reactive protein > or ≤ 3 mg/L. No relationship was found with the majority of traditional CV factors nor with disease variables. Conclusions. Our results corroborated the hypothesis that MPS could reveal subclinical CV dysfunction, supported the utility of BNP measurements as a screening tool, and put in perspective the potential usefulness of complementary approaches in CV risk assessment in RA patients.
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21
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Davis JM, Lin G, Oh JK, Crowson CS, Achenbach SJ, Therneau TM, Matteson EL, Rodeheffer RJ, Gabriel SE. Five-year changes in cardiac structure and function in patients with rheumatoid arthritis compared with the general population. Int J Cardiol 2017; 240:379-385. [PMID: 28427850 DOI: 10.1016/j.ijcard.2017.03.108] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 03/16/2017] [Accepted: 03/23/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients with rheumatoid arthritis (RA) have increased risk of heart failure with preserved ejection fraction. The development and progression of left ventricular dysfunction before onset of clinical heart failure are unknown. The objective of this study was to evaluate longitudinal changes in cardiac structure and function of patients with RA compared with persons in the general population. METHODS A prospective longitudinal study of a population-based cohort of 160 patients with RA and a population-based cohort of 1391 persons without RA (non-RA cohort) was performed. Each participant underwent 2-dimensional, pulsed-wave tissue Doppler echocardiography at baseline and after 4 to 5years of follow-up. Age- and sex-adjusted linear regression models were used to test for differences between the RA and non-RA cohorts in annualized rates of change for echocardiographic parameters. RESULTS Mitral A velocity increased more rapidly among the patients with RA than the non-RA cohort (age- and sex-adjusted parameter estimate, 0.030; P<0.001). Correspondingly, the mean mitral inflow E/A ratio decreased faster in the RA cohort than the non-RA cohort (adjusted parameter estimate, -0.096; P<0.001). The left atrial volume index increased at a higher rate in the RA cohort than the non-RA cohort (adjusted parameter estimate, 0.150; P<0.001). CONCLUSIONS This pattern of echocardiographic findings confirms previous cross-sectional studies and indicates that subclinical changes in diastolic function occur more rapidly over 5years in RA patients than in the general population. Further research into the mechanisms of myocardial disease in these patients and the relationship with disease activity and treatment is warranted.
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Affiliation(s)
- John M Davis
- Division of Rheumatology, Mayo Clinic, Rochester, MN, United States.
| | - Grace Lin
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Jae K Oh
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, United States
| | - Cynthia S Crowson
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Sara J Achenbach
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Terry M Therneau
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN, United States
| | - Eric L Matteson
- Division of Rheumatology, Mayo Clinic, Rochester, MN, United States
| | | | - Sherine E Gabriel
- Division of Epidemiology, Mayo Clinic, Rochester, MN, United States; Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
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22
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Mavrogeni S, Koutsogeorgopoulou L, Dimitroulas T, Markousis-Mavrogenis G, Kolovou G. Complementary role of cardiovascular imaging and laboratory indices in early detection of cardiovascular disease in systemic lupus erythematosus. Lupus 2017; 26:227-236. [DOI: 10.1177/0961203316671810] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Background Cardiovascular disease (CVD) has been documented in >50% of systemic lupus erythematosus (SLE) patients, due to a complex interplay between traditional risk factors and SLE-related factors. Various processes, such as coronary artery disease, myocarditis, dilated cardiomyopathy, vasculitis, valvular heart disease, pulmonary hypertension and heart failure, account for CVD complications in SLE. Methods Electrocardiogram (ECG), echocardiography (echo), nuclear techniques, cardiac computed tomography (CT), cardiovascular magnetic resonance (CMR) and cardiac catheterization (CCa) can detect CVD in SLE at an early stage. ECG and echo are the cornerstones of CVD evaluation in SLE. The routine use of cardiac CT and nuclear techniques is limited by radiation exposure and use of iodinated contrast agents. Additionally, nuclear techniques are also limited by low spatial resolution that does not allow detection of sub-endocardial and sub-epicardial lesions. CCa gives definitive information about coronary artery anatomy and pulmonary artery pressure and offers the possibility of interventional therapy. However, it carries the risk of invasive instrumentation. Recently, CMR was proved of great value in the evaluation of cardiac function and the detection of myocardial inflammation, stress-rest perfusion defects and fibrosis. Results An algorithm for CVD evaluation in SLE includes clinical, laboratory, ECG and echo assessment as well as CMR evaluation in patients with inconclusive findings, persistent cardiac symptoms despite normal standard evaluation, new onset of life-threatening arrhythmia/heart failure and/or as a tool to select SLE patients for CCa. Conclusions A non-invasive approach including clinical, laboratory and imaging evaluation is key for early CVD detection in SLE.
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Affiliation(s)
- S Mavrogeni
- Onassis Cardiac Surgery Center, Athens, Greece
| | - L Koutsogeorgopoulou
- Department of Pathophysiology, School of Medicine, University of Athens, Athens, Greece
| | - T Dimitroulas
- 4th Department of Internal Medicine, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - G Kolovou
- Onassis Cardiac Surgery Center, Athens, Greece
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23
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Tailor TD, Kicska GA, Jacobs JE, Pampaloni MH, Litmanovich DE, Reddy GP. Imaging of Heart Disease in Women. Radiology 2017; 282:34-53. [DOI: 10.1148/radiol.2016151643] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Lee J, Jung SM, Ebert AD, Wu H, Diecke S, Kim Y, Yi H, Park SH, Ju JH. Generation of Functional Cardiomyocytes from the Synoviocytes of Patients with Rheumatoid Arthritis via Induced Pluripotent Stem Cells. Sci Rep 2016; 6:32669. [PMID: 27609119 PMCID: PMC5016736 DOI: 10.1038/srep32669] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 08/12/2016] [Indexed: 12/29/2022] Open
Abstract
Cardiovascular disease is a leading cause of morbidity in rheumatoid arthritis (RA) patients. This study aimed to generate and characterise cardiomyocytes from induced pluripotent stem cells (iPSCs) of RA patients. Fibroblast-like synoviocytes (FLSs) from patients with RA and osteoarthritis (OA) were successfully reprogrammed into RA-iPSCs and OA-iPSCs, respectively. The pluripotency of iPSCs was confirmed by quantitative reverse transcription-polymerase chain reaction and immunofluorescence staining. Established iPSCs were differentiated into cardiomyocytes using a small molecule-based monolayer differentiation protocol. Within 12 days of cardiac differentiation from patient-specific and control-iPSCs, spontaneously beating cardiomyocytes (iPSC-CMs) were observed. All iPSC-CMs exhibited a reliable sarcomeric structure stained with antibodies against cardiac markers and similar expression profiles of cardiac-specific genes. Intracellular calcium signalling was recorded to compare calcium-handling properties among cardiomyocytes differentiated from the three groups of iPSCs. RA-iPSC-CMs had a lower amplitude and a shorter duration of calcium transients than the control groups. Peak tangential stress and the maximum contractile rate were also decreased in RA-iPSC-CMs, suggesting that contractility was reduced. This study demonstrates the successful generation of functional cardiomyocytes from pathogenic synovial cells in RA patients through iPSC reprogramming. Research using RA-iPSC-CMs might provide an opportunity to investigate the pathophysiology of cardiac involvement in RA.
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Affiliation(s)
- Jaecheol Lee
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Seung Min Jung
- Division of Rheumatology, Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Antje D Ebert
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA.,Department of Cardiology and Pneumonology, Göttingen University Medical Center, Göttingen, Germany.,DZHK (German Center for Cardiovascular Research), partner site Göttingen, Germany
| | - Haodi Wu
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Sebastian Diecke
- Max Delbrück Center, Berlin, Germany Berlin Institute of Health, Berlin, Germany
| | - Youngkyun Kim
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Hyoju Yi
- Division of Cardiology, Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Sung-Hwan Park
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
| | - Ji Hyeon Ju
- Division of Rheumatology, Department of Internal Medicine, College of Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, South Korea
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Cardiovascular magnetic resonance in rheumatology: Current status and recommendations for use. Int J Cardiol 2016; 217:135-48. [PMID: 27179903 DOI: 10.1016/j.ijcard.2016.04.158] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Accepted: 04/25/2016] [Indexed: 01/14/2023]
Abstract
Targeted therapies in connective tissue diseases (CTDs) have led to improvements of disease-associated outcomes, but life expectancy remains lower compared to general population due to emerging co-morbidities, particularly due to excess cardiovascular risk. Cardiovascular magnetic resonance (CMR) is a noninvasive imaging technique which can provide detailed information about multiple cardiovascular pathologies without using ionizing radiation. CMR is considered the reference standard for quantitative evaluation of left and right ventricular volumes, mass and function, cardiac tissue characterization and assessment of thoracic vessels; it may also be used for the quantitative assessment of myocardial blood flow with high spatial resolution and for the evaluation of the proximal coronary arteries. These applications are of particular interest in CTDs, because of the potential of serious and variable involvement of the cardiovascular system during their course. The International Consensus Group on CMR in Rheumatology was formed in January 2012 aiming to achieve consensus among CMR and rheumatology experts in developing initial recommendations on the current state-of-the-art use of CMR in CTDs. The present report outlines the recommendations of the participating CMR and rheumatology experts with regards to: (a) indications for use of CMR in rheumatoid arthritis, the spondyloarthropathies, systemic lupus erythematosus, vasculitis of small, medium and large vessels, myositis, sarcoidosis (SRC), and scleroderma (SSc); (b) CMR protocols, terminology for reporting CMR and diagnostic CMR criteria for assessment and quantification of cardiovascular involvement in CTDs; and (c) a research agenda for the further development of this evolving field.
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Abstract
Patients with rheumatoid arthritis (RA) and other inflammatory joint diseases (IJDs) have an increased risk of premature death compared with the general population, mainly because of the risk of cardiovascular disease, which is similar in patients with RA and in those with diabetes mellitus. Pathogenic mechanisms and clinical expression of cardiovascular comorbidities vary greatly between different rheumatic diseases, but atherosclerosis seems to be associated with all IJDs. Traditional risk factors such as age, gender, dyslipidaemia, hypertension, smoking, obesity and diabetes mellitus, together with inflammation, are the main contributors to the increased cardiovascular risk in patients with IJDs. Although cardiovascular risk assessment should be part of routine care in such patients, no disease-specific models are currently available for this purpose. The main pillars of cardiovascular risk reduction are pharmacological and nonpharmacological management of cardiovascular risk factors, as well as tight control of disease activity.
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Erhayiem B, Pavitt S, Baxter P, Andrews J, Greenwood JP, Buch MH, Plein S. Coronary Artery Disease Evaluation in Rheumatoid Arthritis (CADERA): study protocol for a randomized controlled trial. Trials 2014; 15:436. [PMID: 25381560 PMCID: PMC4233100 DOI: 10.1186/1745-6215-15-436] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 10/24/2014] [Indexed: 02/06/2023] Open
Abstract
Background The incidence of cardiovascular disease (CVD) in rheumatoid arthritis (RA) is increased compared to the general population. Immune dysregulation and systemic inflammation are thought to be associated with this increased risk. Early diagnosis with immediate treatment and tight control of RA forms a central treatment paradigm. It remains unclear, however, whether using tumor necrosis factor inhibitors (TNFi) to achieve remission confer additional beneficial effects over standard therapy, especially on the development of CVD. Methods/Design Coronary Artery Disease Evaluation in Rheumatoid Arthritis (CADERA) is a prospective cardiovascular imaging study that bolts onto an existing single-centre, randomized controlled trial, VEDERA (Very Early versus Delayed Etanercept in Rheumatoid Arthritis). VEDERA will recruit 120 patients with early, treatment-naïve RA, randomized to TNFi therapy etanercept (ETN) combined with methotrexate (MTX), or therapy with MTX with or without additional synthetic disease modifying anti-rheumatic drugs with escalation to ETN following a ‘treat-to-target’ regimen. VEDERA patients will be recruited into CADERA and undergo cardiac magnetic resonance (CMR) assessment with; cine imaging, rest/stress adenosine perfusion, tissue-tagging, aortic distensibility, T1 mapping and late gadolinium imaging. Primary objectives are to detect the prevalence and change of cardiovascular abnormalities by CMR between TNFi and standard therapy over a 12-month period. All patients will enter an inflammatory arthritis registry for long-term follow-up. Discussion CADERA is a multi-parametric study describing cardiovascular abnormalities in early, treatment-naïve RA patients, with assessment of changes at one year between early biological therapy and conventional therapy. Trials registration This trial was registered with Current Controlled Trials (registration number: ISRCTN50167738) on 8 November 2013.
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Affiliation(s)
| | | | | | | | | | | | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Leeds Institute for Cardiovascular and Metabolic Medicine, Worsley Building, University of Leeds, Clarendon Way, Leeds LS2 9JT, UK.
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Serhal M, Longenecker CT. Preventing Heart Failure in Inflammatory and Immune Disorders. CURRENT CARDIOVASCULAR RISK REPORTS 2014; 8. [PMID: 26316924 DOI: 10.1007/s12170-014-0392-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Patients with chronic inflammatory diseases are at increased risk for heart failure due to ischemic heart disease and other causes including heart failure with preserved ejection fraction. Using rheumatoid arthritis and treated HIV infection as two prototypical examples, we review the epidemiology and potential therapies to prevent heart failure in these populations. Particular focus is given to anti-inflammatory therapies including statins and biologic disease modifying drugs. There is also limited evidence for lifestyle changes and blockade of the renin-angiotensin-aldosterone system. We conclude by proposing how a strategy for heart failure prevention, such as the model tested in the Screening To Prevent Heart Failure (STOP-HF) trial, may be adapted to chronic inflammatory disease.
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Affiliation(s)
- Maya Serhal
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Chris T Longenecker
- University Hospitals Case Medical Center, Cleveland, OH, USA ; Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Edema and fibrosis imaging by cardiovascular magnetic resonance: how can the experience of Cardiology be best utilized in rheumatological practice? Semin Arthritis Rheum 2014; 44:76-85. [PMID: 24582213 DOI: 10.1016/j.semarthrit.2014.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 10/19/2013] [Accepted: 01/17/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES CMR, a non-invasive, non-radiating technique can detect myocardial oedema and fibrosis. METHOD CMR imaging, using T2-weighted and T1-weighted gadolinium enhanced images, has been successfully used in Cardiology to detect myocarditis, myocardial infarction and various cardiomyopathies. RESULTS Transmitting this experience from Cardiology into Rheumatology may be of important value because: (a) heart involvement with atypical clinical presentation is common in autoimmune connective tissue diseases (CTDs). (b) CMR can reliably and reproducibly detect early myocardial tissue changes. (c) CMR can identify disease acuity and detect various patterns of heart involvement in CTDs, including myocarditis, myocardial infarction and diffuse vasculitis. (d) CMR can assess heart lesion severity and aid therapeutic decisions in CTDs. CONCLUSION The CMR experience, transferred from Cardiology into Rheumatology, may facilitate early and accurate diagnosis of heart involvement in these diseases and potentially targeted heart treatment.
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