Rheumatoid arthritis (RA) is a systemic autoimmune disease that predominantly affects the joints. Additionally, it is known to increase the risk of various cardiovascular diseases including heart failure and pericarditis (inflammation of the outer layer of the heart).
Researchers agree that heart failure is one of the common causes of increased mortality in people with RA and is more common in people with RA than in a population of similar age and gender distribution without RA.
What is heart failure?
Heart failure occurs when the heart muscle fails to pump as much blood as the body requires. Although the heart continues to beat, it is inefficient and cannot supply adequately.
Many studies have connected heart failure to inflammation-related substances. These inflammatory molecules are high in disorders such as rheumatoid arthritis (RA). RA is an autoimmune and progressive chronic disease characterized by an immune system failure and releases various inflammatory mediators in the body that promote inflammation.
Heart failure caused by RA is due to the following:
- Reduced left ventricular (LV) ejection fraction. This is earlier referred to as LV systolic dysfunction.
- Preserved LV ejection fraction. This is earlier referred to as LV diastolic dysfunction.
- Asymptomatic LV systolic dysfunction
What are the factors that increase the risk of heart failure with rheumatoid arthritis?
Causes responsible for an increased risk of heart failure in rheumatoid arthritis (RA) include the following:
Inflammatory mediators may have a role in the onset of heart failure in RA. A study on people with RA who developed heart failure reported a high erythrocyte sedimentation rate (ESR) >39 mm/hour 6 months after the new onset of heart failure. Most individuals developed anemia 6 months after developing heart failure, which indicates the presence of systemic inflammation.
A cross-sectional study reported that an ESR of >16 mm/hour and a C-reactive protein of >10 mg/L were both related to an elevated risk of heart failure, suggesting that there is a significant relationship between active inflammation and heart failure in individuals with RA.
Antirheumatic drug therapy
Disease-modifying antirheumatic drugs can affect the immune status adversely and increase the predisposition to systemic infections and heart muscle inflammation.
- Glucocorticoids: It is believed that the use of glucocorticoids for the treatment of RA increases the risk of heart failure, myocardial infarction, myocarditis, and other causes of mortality. Moreover, it is believed that the risk of a life-threatening condition depends on the dose of glucocorticoids. Large observational research found that the risk of heart failure increased with the daily glucocorticoids administered, such as 7.5 mg/day of prednisone or its equivalent compared to non-users. The cardiovascular risk was higher for people who had continuous prescriptions than for those who had intermittent prescribing of glucocorticoids, and it was higher for those who used glucocorticoids 6 months after a cardiovascular incident than for those who used glucocorticoids earlier. Therefore, studies conclude that continuous use of glucocorticoids, which can reduce inflammation caused by RA, has shown an increased risk of heart failure in people with RA. However, the general population without RA showed no signs of an increased risk of cardiovascular events.
- Nonsteroidal anti-inflammatory drugs (NSAIDs): NSAID usage is rarely associated with the onset of new heart failure; however, it can aggravate preexisting heart failure. The main cause of heart failure aggravation is an increase in afterload caused by NSAID-induced systemic vasoconstriction, which can lead to a further decrease in cardiac contractility and cardiac output in advanced heart failure.
- Antimalarial drugs: Drug-induced cardiomyopathy (a disease of the heart muscles that reduces the ability to pump blood efficiently) can be caused by antimalarial medications such as chloroquine and hydroxychloroquine.
- Tumor necrosis factor (TNF) inhibitors: TNF inhibitors may increase the risk of heart failure in people with RA, but they are usually well-tolerated.
Ischemic heart disease
In the general population, the most common cause of heart failure owing to systolic dysfunction (failure to pump blood to the body) is ischemic cardiomyopathy. Because the risk of coronary disease in people with RA is higher than that in the general population, heart failure occurs from ischemic cardiomyopathy in people with RA.
Secondary amyloidosis (deposit of waxy amyloid protein within heart muscle fiber) caused by chronic inflammation due to RA may result in heart failure owing to infiltrative cardiomyopathy. However, it is a very rare complication.
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Ahlers, Michael J., et al. "Heart Failure Risk Associated With Rheumatoid Arthritis–Related Chronic Inflammation." Journal of the American Heart Association 9(10) May 7, 2020. <https://www.ahajournals.org/doi/10.1161/JAHA.119.014661#:~:text=In%20a%20large%20contemporary%20clinical,factors%20and%20coronary%20artery%20disease>.
Kaplan, M.J. "Cardiovascular complications of rheumatoid arthritis: assessment, prevention, and treatment." Rheum Dis Clin North Am 36.2 May 2010: 405-26. doi: 10.1016/j.rdc.2010.02.002. PMID: 20510241; PMCID: PMC2892739. <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2892739/>.
Sorour, Ahmed A., et al. "Use of Hydroxychloroquine and Risk of Heart Failure in Patients With Rheumatoid Arthritis." The Journal of Rheumatology 48(10) October 2021: 1508-1511; DOI: https://doi.org/10.3899/jrheum.201180 <https://www.jrheum.org/content/48/10/1508>.
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