Rheumatoid disease and the heart: from epidemiology to echocardiography

Beta-blocker use for the stages of heart failure

The 2005 American Heart Association/American College of Cardiology heart failure (HF) guidelines contributed to a renewed focus on "at-risk" patients and emphasized HF as a progressive disease. Patient categorization by stages focused attention on customization of therapy to achieve optimal, evidence-based treatments across the HF continuum. Therapy for risk factors that predispose patients to left ventricular dysfunction or other symptoms may help reduce HF development. beta-Blockers are valuable for treatment of HF; however, the class is heterogeneous, and proper beta-blocker selection for each HF stage is important. beta-Blockers have been used routinely to treat patients with stage A HF with hypertension. Recent controversy regarding the detrimental effects that some beta-blockers have on metabolic parameters has raised inappropriate concerns about the use of any beta-blocker for diabetes. beta-Blockade is standard therapy for the patient with stage B HF who has had a myocardial infarction, but few data are available concerning use in asymptomatic patients with left ventricular dysfunction. Additionally, beta-blockers are part of the core therapy for stage C HF and selected patients with stage D HF. This review examines the role and use of beta-blockers in each HF stage through an evidence-based approach to provide better understanding of their importance in this progressive disease. PubMed searches (1980-2008) identified large clinical trials that evaluated cardiovascular events and outcomes in any HF stage or hypertension. Search terms were heart failure, hypertension, beta-blocker, ACEI, ARB, and calcium channel blocker AND blood pressure coronary artery disease, diabetes, efficacy, left ventricular dysfunction, metabolism, mortality, myocardial infarction, or stroke.

Left Ventricular Systolic Dysfunction in Rheumatoid Disease

OBJECTIVES

This study sought to ascertain whether left ventricular systolic dysfunction (LVSD) is more common among clinic patients with rheumatoid disease (RD) compared with the general population, and to assess the diagnostic utility of brain natriuretic peptide (BNP).

BACKGROUND

Patients with RD are at increased risk of ischemic heart disease. However, there are few large echocardiographic studies identifying cardiac dysfunction in RD. We hypothesized that LVSD would be more prevalent in RD patients than in the general population.

METHODS

A total of 226 hospital out-patients with RD (65% women) underwent clinical evaluation, electrocardiography (ECG), echocardiography, and plasma BNP assay (218 patients). Prevalence of LVSD was compared with local population estimates.

RESULTS

Definite LVSD (left ventricular ejection fraction <40%) occurred in 5.3% of the RD group: standardized prevalence ratio, 3.20; 95% confidence interval, 1.65 to 5.59. Median BNP values were higher in patients with LVSD compared with those without: 16.6 pmol/l versus 8.5 pmol/l, p < 0.005, although values between the two groups overlapped. One in nine patients with an abnormal ECG had definite LVSD.

CONCLUSIONS

Definite LVSD was three times more common in RD patients than in the general population. Given the prognostic benefits of treating LVSD, echocardiographic screening of RD patients with an abnormal ECG may be worthwhile.