Do Your Patients With RA Have Asymptomatic LV Systolic Dysfunction?

TOPIC SERIES: CVD PREVENTION IN RHEUMATIC DISEASE

Rheumatoid arthritis (RA) is chronic inflammatory disease associated with an increased incidence of cardiovascular disease. A recent prospective cohort study found that hypertension developed in 15.1% of those with RA, and myocardial infarction was diagnosed in 4.3% of those with RA within the study follow-up period of 5 years.¹ The authors concluded that chronic inflammation may play a role in the pathogenesis of cardiovascular disease. 

To investigate whether asymptomatic left ventricular systolic dysfunction (LVSD) was more prevalent in those with RA, Cioffi and colleagues prospectively recruited patients with RA who had no history of preexisting cardiac disease and compared them with matched controls. The study was published in the journal Echocardiography.²

Echocardiography was performed on 198 patients with RA and no overt cardiovascular disease and on 198 age- and comorbidity-matched controls. Stress-corrected mid-wall shortening (sc-MS) was used as an index measure of LVSD. Sc-MS has been used to quantify concentric left ventricular (LV) hypertrophy that can result from carotid atherosclerosis and has been shown to be impaired even while LV ejection fraction (LVEF) is preserved.³

Researchers found that in patients with RA, 56% had impairments in sc-MS and 3% had decreased LVEF.² In matched controls, sc-MS was impaired in 15% and LVEF was decreased in 1%. Those with RA also were more likely to exhibit valvular calcifications of the aortic and mitral valves and were also more likely to have evidence of concentric LV hypertrophy compared with matched controls.

Multivariable logistic regression analysis revealed an independent association between RA and impaired sc-MS (Exp β 2.01 [confidence interval 1.12-3.80], P = .02).

Summary and Clinical Applicability

RA appears to be an independent risk factor for increased LVSD when sc-MS is used as a surrogate marker for LVSD.² The authors write, “RA emerges as a condition closely related to LVSD. These findings might explain the high risk for adverse cardiovascular events in patients with RA.”  

Thus, patients with RA without overt cardiac disease and preserved LVEF may still have underlying abnormal LV systolic function, and risk factors for the progression of LVSD should be closely controlled.

References

1. Innala L, Sjöberg C, Möller B, et al. Co-morbidity in patients with early RA – inflammation matters. Arthritis Res Ther. 2016;18(1):33.

2. Cioffi G, Viapiana O, Ognibeni F, et al. Prevalence and factors associated with subclinical left ventricular systolic dysfunction evaluated by mid-wall mechanics in RA. Echocardiography. 2016 Feb 18. [Epub ahead of print]

3. Cioffi G, Senni M, Tarantini L, et al. Analysis of circumferential and longitudinal left ventricular systolic function in patients with non-ischemic chronic heart failure and preserved ejection fraction (from the CARRY-IN-HFpEF study). Am J Cardiol. 2012;109(3):383-389.