Rheumatoid Arthritis In The Heart

'A Silent Killer About Which Much Is Still Not Fully Understood'

The Short Answer –

Finding Rheumatoid Arthritis in the heart is an extremely serious condition.

While the heart may not be the first place you think of being affected by Rheumatoid Arthritis, when it is, then the effects can be fatal.

Spotting the early signs of it’s development  is essential, particularly if you are already diagnosed with RA. Your treatment plan will have to be adjusted immediately as this is a life threatening condition.

Here we cover what to look for and the most probably treatment amendments that will have to be made. 

Rheumatoid Arthritis In The Heart – What Is It?

Rheumatoid arthritis is an auto-immune disease whereby your bodies’ own protective immune system becomes confused and, instead of attacking foreign invaders such as bacteria, instead turns itself on your own blood cells and starts attacking your synovial fluid.

Synovial fluid is typically found as lubricant around your joints – which is why rheumatoid arthritis is so commonly associated with painful, damaged fingers and toes.

Why rheumatoid arthritis actually affects your heart at all is actually unknown. However, the fact that is does is undisputed from the evidence.

A review of various studies into the link between rheumatoid arthritis and cardiovascular disease in 2014 concluded that the increased risk made RA sufferers between 1.5-2 times more likely to develop heart disease if they had RA. 

Why this link exists is however is somewhat unclear. The inflammation created as part of your bodies immune response to being attacked has been given much of the blame.

It is thought that just as the inflammation can attack the synovium (synovial fluid around your joints), it can also attack your endothelium. This is the innermost layer of blood vessels.

When it does this, it will damage your blood vessel lining, leaving it much more likely to suffer with fatty deposits or cellular debris (plaque) that attach themselves to it and form a build up in the artery.

As this plaque/ fat builds up, so it narrows the usable space in your arteries, which in turn reduces the blood flow to your heart and raises your blood pressure.

If you suffer with rheumatoid arthritis in the heart, the plaque that forms is also much more likely to go brittle and is at high risk of rupturing, again causing a heart attack or stroke.

The actual risk of suffering with cardiovascular disease (in other words heart attacks, atherosclerosis and stroke) if your rheumatoid arthritis spreads to your heart is significantly greater than just having any of the normal ‘risk factors’ such as an unhealthy lifestyle, diabetes or being a smoker.

In actual fact, according to a review published in the Nature Reviews Rheumatology Journal, cardiovascular disease caused by rheumatoid arthritis in the lungs is responsible for 50% of all premature deaths from the disease.

Then there is possibility of developing atrial fibrillation, which is medical speak for an irregular heartbeat that typically shows a five fold increase in the chances of a stroke, if not properly managed.

A further study this time conducted in 2015 by the Mayo Clinic, backed this up by concluding that people with rheumatoid arthritis are at significantly greater risk of also suffering with atrial fibrillation. 

This same study also noted an increase in diastolic dysfunction from patients with rheumatoid arthritis, also known as a problem with how the heart fills with oxygenated blood before pumping it around the body.

Then there is the distinct possibility of searing chest pain caused when the pericardium is attacked by the same inflammatory process.

The pericardium is a double layered sac that surrounds the heart, but when RA attacks it, the result is the inflamed sacs start to rub together causing bouts of intense pain.

And finally there is also the possibility of rheumatoid nodules forming on your heart. We’ve looked at rheumatoid nodules before and in essence they are harmless in themselves.

However, if they do form on your heart, these would most likely impair it’s normal functioning, resulting again in potentially higher blood pressure and cardiovascular disease.

The potential effects of rheumatoid arthritis on your heart are therefore clear and well proven, even though despite research and considerable theorising, the precise reason for RA to impact on your heart in the first place, remains unproven.

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Symptoms Of Rheumatoid Arthritis In The Heart

The really tricky part with rheumatoid arthritis in the heart is that it’s symptoms can be silent – or at best very difficult to spot.

In essence, symptoms from cardiovascular disease frequently only become evident once someone has suffered with a stroke or a heart attack – by which point it is often far too late.

Typical symptoms include –

  • Chest Pain
  • A Persistent Cough
  • Shortness Of Breath

However, just having Rheumatoid Arthritis and one of the major cardiovascular risk factors such as being a smoker, having high pressure or high cholesterol should see you put on the list at highest risk of developing Rheumatoid Arthritis in the heart (if you have not already developed it)

Diagnosis For Rheumatoid Arthritis In The Heart

With symptoms being potentially extremely difficult to spot in isolation, diagnosis is often only currently carried out based on the traditional tell-tale symptoms of rheumatoid arthritis appearing in other parts of the body.

This creates a serious problem though if your rheumatoid arthritis starts to develop in your heart before affecting other areas of your body – it could potentially be highly advanced before signs

High blood pressure is one potential indicator, but again sometimes even that will only show itself, once damage to the heart has already taken place.

Normal diagnosis for cardiovascular diseases such as stroke revolves around assessing your likelihood of suffering such an attack.

Doctors make an assessment based on what is known as a CHADS2 or the newer version known as the CHADS2-DS2-VASc scorecard.

Basically, points are awarded for risk factors such as whether you have had congestive heart failure, suffer with hypertension (high blood pressure), your age, diabetes, gender and history of vascular disease.

Some factors score 2 points such as if you are over 75 or have had a previous stroke or TIA.

However, this score is purely for predicting the likelihood of strokes in patients with non valvular atrial fibrillation and is therefore no help with rheumatoid arthritis.

Unfortunately, this is typical of all potential risk assessments for any form of cardiovascular disease.

None of the current risk assessments for the likelihood of cardiovascular disease are that much help when it comes to RA.

Most focus around predictions of risk based on medical history and lifestyle information.

This isn’t just my opinion – it’s been backed up by many specialist rheumatologists/ cardiologists and was further highlighted by the findings of a big study across 7 countries in 2017 by Crowson et al for the Oxford Academic (Rheumatology).

They concluded that all the popular risk calculators (QRISK2, EULAR Multiplier and ERS-RA for the medical readers) were no more effective than any other standard calculator when applied to patients with rheumatoid arthritis. 

Current assessments take no account of inflammation or the effects of certain medications on it.

Gaining a better understanding of exactly how and why inflammation from rheumatoid arthritis impacts on the heart would help greatly.

It is generally accepted that rheumatologists need to come up with a much

In addition to the traditional factors that indicate likely cardiovascular risk, there needs to be some allowance for current levels of RA development and speed of activity, further consideration for the length of time RA has been present, any current disability and

Treatment For Rheumatoid Arthritis In The Heart

Treatment for rheumatoid arthritis in the heart is also made more difficult because of no obvious direct guidelines or recommendations.

Patients with rheumatoid arthritis and any of the generally accepted risk factors should be assessed immediately and potentially receive adjusted treatment, although sadly this is not always the case.

In many cases, even just one other ‘risk factor’ should see you being referred to a cardiologist for regular monitoring as well as a change in your treatment plan from your rheumatologist.

This modified treatment should include the following –

a) Much tighter control of the inflammation.

Methotrexate is now considered to be the ‘gold standard’ treatment for RA and it is notably good for your cardiovascular system.
This has largely replaced the use of NSAIDs for inflammation control as NSAIDs can actually increase the risk of heart problems.

b) A reduction in any medications that might otherwise risk damage to the heart.

These include Corticosteroids such as Prednisone and all of the NSAIDs as mentioned above.

c) Open support for lifestyle changes that might reduce general risk of heart disease.

  • These general lifestyle changes include –
    Stopping smoking as a no1 priority,
  • Monitor and take steps to keep your blood pressure healthy
  • Ensure your diabetes (if you suffer with it) is under good control
  • Eat a ‘healthy heart’ diet including taking cholesterol lowering medications if tests show elevated levels at any point.
    exercising within limits and
  • Working with your doctor to keep all drug side effects under strict control.

d) Get all other rheumatoid arthritis symptoms under good control – and keep them there.

The really good news for those patients who catch their rheumatoid arthritis early and before the inflammation can start affecting their heart is that ‘well controlled RA’ shows no such dramatic increased risk of mortality related to cardiovascular disease.

Indeed, it is fair to say that the risk of heart complications from RA is directly linked to how well controlled your disease is (as backed up by Urman et al in 2019

The Final Word –

Cardiovascular disease (heart attack, stroke etc) may not be the first thing you think of following a diagnosis of RA, but may no mistake – Rheumatoid arthritis in the heart is no minor complication.

Not only is it responsible for 50% of all premature deaths from RA, it is also a silent killer and will develop without you even knowing it, if you let your rheumatoid arthritis develop unchecked.

As with all forms of RA however, the key is early diagnosis of the disease in general and then early preventative measures. This is especially important here, because of the increased mortality rates.

Hopefully, in the future as we start to understand more about the relationship between inflammation and RA in the heart, then more standardised guidelines both for diagnosis and treatment may be put together.

In the meantime however, any perceived risk from a poor lifestyle, other drugs that list heart problems as a potential consequence or symptoms of developing heart disease should see you immediately referred to a cardiologist.

As always though, it is up to you to understand both the importance of chest pain/ coughs etc if you have RA, but also to be completely honest if you sometimes have high blood pressure or are even an occasional smoker.

With no cure, we have to rely on prevention and prevention only happens in advance with a good understanding of the disease and a completely open relationship about the risk factors – as well as a real commitment to make changes where necessary to control your Rheumatoid Arthritis before it becomes too late.

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References –

1. Cynthia S Crowson MS, Katherine P Liao MD MPH, John M Davis, III MD, Daniel H Solomon MD MPH, Eric L Matteson MD MPH, Keith L Knutson PhD, Mark A Hlatky MD, and Sherine E Gabriel MD MSc. (October 2013). Rheumatoid Arthritis and Cardiovascular Disease. The American Heart Journal.
2. Deborah P. M. Symmons & Sherine E. Gabriel. (May 2011). Epidemiology of CVD in rheumatic disease, with a focus on RA and SLE. Nature Reviews Rheumtology.
3. A. Kirstin Bacani ,1 Cynthia S. Crowson ,1,2 Véronique L. Roger,2,3 Sherine E. Gabriel,1,2 and Eric L. Matteson1,2. (March 2015). Increased Incidence of Atrial Fibrillation in Patients with Rheumatoid Arthritis. BioMed Research International.
4. Crowson CS, Gabriel SE, Semb AG, van Riel PLCM, Karpouzas G, Dessein PH, Hitchon C, Pascual-Ramos V, Kitas GD. (July 2017). Rheumatoid arthritis-specific cardiovascular risk scores are not superior to general risk scores: a validation analysis of patients from seven countries. Rheumatology (Oxford)
5. Arielle Urman, Nicholas Taklalsingh, Cristina Sorrento, and Isabel M. McFarlane. (Oct 2018). Inflammation beyond the Joints: Rheumatoid Arthritis and Cardiovascular Disease. SciFed Journal of Cardiology.
 

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