Rheumatoid heart disease

The prevalence of rheumatoid arthritis in the population is 0.5-1%. The disease is more often observed in women (the ratio to men is 2:1-3:1). The primary localization of autoimmune inflammation in rheumatoid arthritis is the synovial membrane of the joints, but other organs are often involved in the pathological process, in particular the cardiovascular system. Clinically obvious heart damage is diagnosed in 2-15% of patients, according to autopsy results - in 70-80%.

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Symptoms of Rheumatoid Heart Disease

In the vast majority of cases, rheumatoid heart disease is asymptomatic.

Pericarditis with clinical manifestations is recorded in no more than 2% of cases. According to studies using echocardiography, also performed on small samples of patients with rheumatoid arthritis, the frequency of pericarditis or pericardial effusion ranges from 1 to 26%. In a single study using transesophageal echocardiography in 30 patients with rheumatoid arthritis, pericarditis was detected in 13% of cases (and not detected in controls).

There is a close relationship between the likelihood of pericarditis and the level of rheumatoid factor, nodular lesion and ESR (more than 55 mm/h). In case of acute pericarditis, patients complain of pain behind the breastbone radiating to the left shoulder, back, epigastric region. The pain is severe, long-lasting, accompanied by dyspnea, intensifies in the supine or left lateral position. Edema of the lower extremities may be observed. During examination, tachycardia and pericardial friction rub, sometimes atrial fibrillation (flutter) are observed. A characteristic feature of pericardial exudate is a low glucose level combined with a high content of protein, LDH and rheumatoid factor. Occasionally, cardiac tamponade and constrictive pericarditis may develop.

Rheumatoid myocarditis is rarely recognized, although according to autopsy data in foreign studies it is diagnosed in 25-30% of cases, and it is associated with active RA with extra-articular manifestations, high titer of rheumatoid factor, antinuclear antibodies and signs of systemic vasculitis. Rarely, cardiomyopathy is associated with amyloid infiltration.

Clinical signs of myocarditis include rhythm and conduction disturbances, the appearance of the third or fourth heart sound, systolic murmur, nonspecific changes in the ST segment and P wave during auscultation, and focal or diffuse changes in myocardial scintigraphy. Left ventricular diastolic dysfunction, established by echocardiography, may be a consequence of rheumatoid myocarditis,

Rheumatoid heart defects in RA are diagnosed in 2-10% of patients (according to the data of the Department of Faculty Therapy named after Academician A.I. Nesterov of the Russian State Medical University - in 7.1% of patients).

Damage to the heart valves in rheumatoid arthritis is caused by both a chronic, recurrent inflammatory process and granulomatosis and/or vasculitis. Heart defects often develop in the case of a long-term (many-year) course of erosive RA with a high level of rheumatoid factor and extra-articular manifestations. At the same time, rheumatoid heart defects are usually not accompanied by severe hemodynamic disturbances and clinical manifestations. Severe defects are rarely observed. Mitral regurgitation is more often detected in patients with rheumatoid nodules, which allows us to think about the association of valve damage and the severity of systemic manifestations of RA. One of the causes of severe mitral regurgitation is a rupture of the mitral complex structures in the case of localization of rheumatoid granuloma (node) in it. There is also evidence that aortic insufficiency in RA is characterized by a progressive course in comparison with aortic defects in other diseases.

Diagnosis of rheumatoid heart disease

The main diagnostic method for rheumatoid pericarditis is transthoracic echocardiography, which allows detecting pericardial effusion and decreased diastolic filling during inspiration. Auxiliary methods include multispiral computed tomography and magnetic resonance imaging (MRI); these studies may be necessary when deciding on surgical treatment.

ECG changes characteristic of pericarditis may be nonspecific or absent in patients with RA, but it is possible to detect such classic signs as electrical alternans and diffuse ST segment elevation.

The main diagnostic method for rheumatoid myocarditis is transthoracic color Dopplerography, which allows diagnosing diffuse or nodular thickening of the mitral or aortic valve leaflets, which distinguishes these changes from echocardiographic signs of rheumatic valvulitis. Daily Holter ECG monitoring allows detecting ventricular and supraventricular extrasystoles, as well as assessing their clinical significance.

The etiological interpretation of heart defects in RA has always presented great difficulties. Вуwaters proposed to distinguish 3 subgroups in the group of patients with heart defects and chronic arthritis:

• a combination of two diseases - rheumatic heart disease (RHD) and RA [“combined form of rheumatic fever (RF) and RA”];
• true rheumatoid heart defects;
• Jaccoud's postrheumatic arthropathy.

Domestic authors have described another variant of the disease, which has the following features:

• the onset of episodes of reversible arthritis in childhood and adolescence with the formation of heart defects in some cases, which corresponded to the picture of RA;
• the addition after a long “bright” period of persistent, chronic arthritis with a typical picture of RA, the presence of extra-articular manifestations (most often others - interstitial pulmonary fibrosis, Raynaud's syndrome) and seropositivity for rheumatoid factor.

However, the rarity of this variant of the disease, the need for many years of careful monitoring of symptoms do not allow us to hope for rapid progress in understanding the discovered phenomenon in the coming years, which is disappointing, because, as Academician N.A. Mukhin writes, “each patient enriches our understanding of the disease with new details,” and cites the statement of R. Vikhrov: “Rare diseases are important because they affect not only our feelings, but also our mind.”

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Treatment of rheumatoid heart disease

Treatment of rheumatoid heart disease is carried out in accordance with generally accepted standards with mandatory prescription of disease-modifying treatment (methotrexate, deflunomide, etc.) to control RA activity. Exudative pericarditis is an indication for the prescription of a short course of glucocorticoids. In some cases, pericardiocentesis may be required.

Prognosis of rheumatoid heart disease

According to the limited data available, the presence of rheumatoid heart disease does not significantly affect the prognosis in patients with RA.