Disease activity is associated with LV dysfunction in rheumatoid arthritis patients without clinical cardiovascular disease

Cardiovascular Risk Factors and Echocardiographic Findings in a Predominantly Black Population With Rheumatoid Arthritis and Heart Failure

Among white rheumatoid arthritis (RA) cohorts, heart failure with preserved ejection fraction is the most prevalent type of heart failure (HF). We aimed to assess the type of HF affecting Black RA patients. A total of 64 patients with RA-HF were compared with age-, sex-, and race-matched RA patients without HF. Left ventricular ejection fraction, wall motion abnormalities, left ventricle (LV) mass, and wall thickness were reviewed. About 87.3% were Black and 84.4% were women, with a mean age of 69.6 ± 1.38 (± SEM) and body mass index (kg/m 2 ) of 29.6 ± 1.07. RA-HF patients had higher rates of hypertension (HTN), chronic kidney disease, and atrial fibrillation. However, 66.7% had ≥3 cardiovascular risk factors compared with RA patients without HF. 2D echocardiograms of RA-HF revealed that 62.3% had left ventricular ejection fraction ≥50%, 37% had diastolic dysfunction, and 43.1% had wall motion abnormalities. LV mass and relative wall thickness measurements indicated LV eccentric remodeling. The odds ratio for HF was 4.7 (CI, 1.5-14.53), P < 0.01, among the RA-HTN group and 3.5 (CI, 1.091-11.7) P < 0.01 among smokers. In our predominantly Black RA-HF patients, heart failure with preserved ejection fraction was the most common type of HF. HTN was associated with the highest OR for HF. Eccentric hypertrophic remodeling, a known poor prognostic indicator for cardiovascular events, was found. Further studies are required to confirm our findings.

Subclinical left ventricular dysfunction in rheumatoid arthritis: findings from the prospective Porto-RA cohort

AIM

Patients with rheumatoid arthritis (RA) have an increased risk of cardiac dysfunction and heart failure (HF) due to a pro-inflammatory state. Detecting cardiac dysfunction in RA is challenging as these patients often present preserved ejection fraction (EF) but may have subclinical ventricular dysfunction. Echocardiographic strain analysis is a promising tool for early detection of subclinical left ventricular systolic dysfunction (LVSD). This study assesses the prognostic role of strain analysis in RA.

METHODS AND RESULTS

Prospective study of 277 RA patients without known heart disease and preserved EF, categorized by left ventricular global longitudinal strain (GLS): normal GLS (≤ - 18%) vs. subclinical LVSD (> - 18%). Primary outcome was a composite of myocardial infarction, HF hospitalization, stroke, or cardiovascular death (MACE). Mean age was 57 years, 79% female. Although mean GLS was within normal (- 20 ± 3%), subclinical LVSD was observed in 24% of patients (n = 67) and was positively correlated with older age (OR 1.54 per 10 years; p < 0.001) and comorbid conditions, such as dyslipidemia (OR 2.27; p = 0.004), obesity (OR 2.29; p = 0.015), and chronic kidney disease (OR 8.39; p = 0.012). Subclinical LVSD was independently associated with a 3.9-fold higher risk of MACE (p = 0.003) and a 3.4-fold higher risk of HF hospitalization/cardiovascular death (p = 0.041). A GLS threshold of > - 18.5% provided optimal sensitivity (78%) and specificity (74%) in identifying patients at elevated MACE risk (AUC = 0.78; p < 0.001).

CONCLUSION

Subclinical LVSD, identified by reduced GLS, was strongly associated with adverse cardiovascular events in RA. Whether these findings have therapeutic implications is worth exploring in clinical trials.

Epicardial Adipose Tissue and Left Ventricular Systolic Function in Rheumatoid Arthritis Assessed by Two-Dimensional Speckle Tracking Echocardiography

Introduction Epicardial adipose tissue (EAT) is an emerging cardiovascular biomarker. Subclinical left ventricular (LV) systolic dysfunction is common in rheumatoid arthritis (RA). The aim of this study was to assess LV systolic function using two-dimensional speckle tracking echocardiography (2D-STE) and investigate its association with EAT in RA patients without clinical cardiovascular disease (CVD). Methods 60 RA patients without manifestations of CVD and 60 age- and gender-matched healthy controls have been recruited for the study. We assessed LV systolic function and EAT in all subjects using conventional echocardiography and 2D-STE. EAT was measured as the relative echo-free region between the free wall of the right ventricle and the visceral layer of the pericardium at end-systole. Results Global longitudinal strain (GLS) was decreased and EAT was increased in the RA group compared to the control group. GLS was reduced as EAT increased in RA patients (r=-0.273, P=0.035). After adjusting for confounders, multivariate linear regression analysis revealed a weakened correlation between EAT and GLS.Age and disease activity scores28 were independent factors influencing GLS in RA. Conclusion RA patients have significantly thickened EAT compared with controls. 2D-STE can detect early LV myocardial systolic dysfunction in RA, as shown by lower GLS. Accumulation of EAT is associated with lower GLS, but older age and higher disease activity may play a greater role in LV myocardial systolic dysfunction in RA.

Detection of myocardial dysfunction using global longitudinal strain with speckle-tracking echocardiography in patients with vs without rheumatoid arthritis: a systematic review and meta-analysis

OBJECTIVES

Rheumatoid arthritis (RA) is a systemic autoimmune disorder primarily involving the peripheral joints. Systemic involvement can occur, including myocardial dysfunction. Speckle tracking echocardiography (STE) is a novel diagnostic study which is recently being used to detect subclinical cardiac dysfunction. Global longitudinal strain (GLS) by STE is more sensitive than standard echocardiographic parameters to detect occult cardiac dysfunction.

METHODS

A systematic search of PUBMED, EMBASE, Cochrane, and Google Scholar databases was performed to identify studies comparing the STE parameters between RA and non-RA patients.

RESULTS

Left ventricular (LV) GLS was significantly lower in patients with RA compared to non-RA patients with a standard mean difference (SMD) of -1.09 (-1.48--0.70, P < 0.001). LV Global Circumferential Strain (GCS) was reported in five studies, and it was found to be lower in RA patients with an SMD of -1.25 (-2.59--0.10; P < 0.0010). Meta regression analysis studies failed to show any significant impact of disease duration, activity, age, sex and BMI on LV GLS and RV GLS.

CONCLUSIONS

RA patients have lower LV GLS and LV GCS compared to controls suggesting impaired myocardial dysfunction. Further studies need to be done to delineate the importance of lower GLS in asymptomatic rheumatoid patients to guide disease management and risk factor modification in this selected population.

A preliminary study on the evaluation of left atrial function of rheumatoid arthritis by two dimensional speckle tracking imaging

To evaluate the changes of left atrial (LA) geometry and function in patients with rheumatoid arthritis (RA) by conventional echocardiography and two-dimensional speckle tracking imaging (2D-STI). We enrolled 46 RA patients with a duration of < 5 years as Group I, 40 RA patients with a duration of ≥ 5 years as Group II, and 40 normal subjects as the control group. Conventional echocardiography was conducted to measure traditional parameters. The LA strain during reservoir phase (LASr), LA strain during conduit phase (LAScd), LA strain during contraction phase (LASct), and LA global longitudinal strain (LAGLS) were obtained from 2D-STI. Related ultrasound results were compared. The LASct was significantly higher in Group I than in control group (P < 0.05). The LASr, LAScd, and LAGLS were significantly lower in Group I than in control group (all P < 0.05). The LASr, LAScd, LASct, and LAGLS were significantly lower in Group II than in control group and Group I (all P < 0.05). The function of LA impaired in RA patients, and the impairment aggravated with the clinical course of RA patients. 2D-STI technology can early and accurately evaluate the LA function of RA patients by evaluating LASr, LAScd, LASct, and LAGLS.

Ischemic Heart Disease and Rheumatoid Arthritis-Two Conditions, the Same Background

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.

Evaluation of left ventricular systolic synchrony by peak strain dispersion in patients with rheumatoid arthritis

Objective

To investigate the clinical value of the peak strain dispersion (PSD) in evaluating left ventricular (LV) systolic synchrony in patients with rheumatoid arthritis (RA).

Methods

One hundred eleven patients with RA were divided into two groups according to their disease duration: <5 years (Group I, n = 60) and ≥5 years (Group II, n = 51). The control group comprised 57 healthy subjects without RA. All three groups were examined by transthoracic two-dimensional echocardiography. Traditional parameters were measured by conventional echocardiography. Two-dimensional speckle tracking imaging was used to analyze the PSD and LV global longitudinal strain (LVGLS). Related ultrasound and blood test results were analyzed and compared.

Results

The PSD gradually increased in the order of the control group, Group I, and Group II, and the difference among the groups was statistically significant. The LVGLS gradually decreased in the order of the control group, Group I, and Group II, and the difference among the groups was statistically significant. The PSD was negatively correlated with the LVGLS.

Conclusions

LV systolic synchrony in patients with RA gradually decreases as the disease course progresses. The PSD can be used as a new reliable index to evaluate LV systolic synchrony.

The Link Between Autonomic Nervous System and Rheumatoid Arthritis: From Bench to Bedside

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.

Disease severity affects myocardial functions in patients with treatment-naive early rheumatoid arthritis

OBJECTIVES

The cross-sectional study aimed to assess myocardial functions using global longitudinal strain (GLS) echocardiography and arrhythmia parameters with treatment naive newly diagnosed rheumatoid arthritis (RA) and no clinical evidence of cardiovascular disease (CVD).

METHODS

Seventy seven newly diagnosed treatment-naive RA patients were enrolled. Disease severity was evaluated according to rheumatoid factor (RF) and anti-citrullinated protein antibodies (ACPA) positivity, and Disease Activity Score 28 C-reactive protein (DAS28 CRP). Myocardial functions were assessed using conventional echocardiography and GLS technique and electrocardiogram parameters cQT and Tp-e/cQT.

RESULTS

Twenty three patients had severe disease while 54 patients were non-severe. The Left Ventricle GLS (17.98 ± 1.24 vs 21.29 ± 1.03, P < .001), cQT (428.71 ± 9.05 vs 394.61 ± 17.83, P < .001), Tp-e/cQT (0.19 ± 0.02 vs 0.16 ± 0.01, P < .001) for severe RA patients was reduced compared to RA non-severe patients. Penalized maximum likelihood estimation logistic regression analysis revealed LVGLS as the only significantly independent predictor of severe RA disease (OR 0.70, CI 95% 0.52-0.92, P = .001). Receiver operating characteristic (ROC) curves of the LVGLS was revealed 19.9 as GLS discriminative value with 88.8% positive predictive value for predicting severity. Severe RA risk increases when log-odds value was over 0, corresponds to LVGLS value less than 18 by partial effect plots.

CONCLUSION

RA severity was associated with lower LV systolic myocardial function and increased arrhythmia parameters. Only LVGLS was significantly independent predictor of RA disease severity.

Echocardiography in Autoimmune Rheumatic Diseases for Diagnosis and Prognosis of Cardiovascular Complications

Autoimmune rheumatic diseases are systemic diseases frequently affecting the heart and vessels. The main cardiovascular complications are pericarditis, myocarditis, valvular disease, obstructive coronary artery disease and coronary microcirculatory dysfunction, cardiac failure and pulmonary hypertension. Echocardiography, including transthoracic two and three-dimensional echocardiography, Doppler imaging, myocardial deformation and transesophageal echo, is an established and widely available imaging technique for the identification of cardiovascular manifestations that are crucial for prognosis in rheumatic diseases. Echocardiography is also important for monitoring the impact of drug treatment on cardiac function, coronary microcirculatory function, valvular function and pulmonary artery pressures. In this article we summarize established and evolving knowledge on the role of echocardiography for diagnosis and prognosis of cardiovascular abnormalities in rheumatic diseases.

Is There a Brain/Heart Interaction in Rheumatoid Arthritis and Seronegative Spondyloartropathies? A Combined Brain/Heart Magnetic Resonance Imaging Reveals the Answer

PURPOSE OF REVIEW

To present the interaction between brain/heart and emphasize the role of combined brain/heart magnetic resonance imaging (MRI) in patients with rheumatoid arthritis (RA) and other seronegative spondyloarthropathies (SNA).

RECENT FINDINGS

Both traditional cardiovascular disease (CVD) risk factors and intrinsic RA/SNA features contribute to the increased CVD-related morbidity/mortality. CVD in RA usually occurs a decade earlier than age- and sex-matched controls, and RA patients are twice more likely to develop myocardial infarction irrespective of age, history of prior CVD, and traditional CVD risk factors. RA also increases risk of non-ischemic heart failure (HF), valvular disease, and myo-pericarditis. CVD in SNA affects more commonly patients with long-standing disease. Ascending aortitis, aortic/mitral insufficiency, conduction defects, and diastolic dysfunction are the commonest findings in ankylosing spondylitis (AS). CVD is also the leading cause of death in psoriatic arthritis (PsA), due to myopericarditis, diastolic dysfunction, and valvular disease. Brain damage, due to either ischemic or hemorrhagic stroke and silent vascular damage, such as white matter hyperenhancement (WMH), is increased in both RA/SNA and may lead to cognitive dysfunction, depression, and brain atrophy. Magnetic resonance imaging (MRI) is ideal for serial brain/heart evaluation of patients with systemic diseases. RA/SNA patients are at high risk for brain/heart damage at early age, irrespectively of classic risk factors. Until more data will be obtained, a combined brain/heart MRI evaluation can be proposed in RA/SNA with new onset of arrhythmia and/or HF, cognitive dysfunction and/or depression.