Rheumatoid heart disease

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

[1], [2], [3],

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 incidence of pericarditis or pericardial effusion ranges from 1 to 26%. In a single study using transvesic echocardiography in 30 patients with rheumatoid arthritis, pericarditis was detected in 13% of cases (and was not detected in control subjects).

There is a close relationship between the likelihood of pericarditis and the level of rheumatoid factor, nodular lesion, and ESR index (more than 55 mm / h). In the case of acute pericarditis, patients complain of chest pain with irradiation in the left shoulder, back, epigastric region. The pain is severe, prolonged, accompanied by shortness of breath, worse in the supine position on the back or on the left side. Swelling of the lower extremities may be observed. On examination, tachycardia and pericardial friction noise are observed, sometimes atrial fibrillation (flutter). A characteristic feature of pericardial exudate is a low glucose level in combination with high protein, LDH and rheumatoid factor. Occasionally, a cardiac tamponade and constrictive pericarditis can be formed.

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

Clinical signs of myocarditis include disturbances of rhythm and conduction, the appearance of auscultation of III or IV tone, systolic noise, nonspecific changes in the ST segment and P wave in myocardial scintigraphy detect focal or diffuse changes. Diastolic dysfunction of the left ventricle, established by echocardiography, may be a consequence of rheumatoid mocarditis,

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

The defeat of heart valves in rheumatoid arthritis is due to both a chronic, recurrent inflammatory process, and granulomatosis and / or vasculitis. Heart defects often develop with prolonged (long-term) flow of erosive RA with a high level of rheumatoid factor and extravagant manifestations. At the same time, rheumatoid heart defects are usually not accompanied by severe hemodynamic disorders and clinical manifestations. Severe malformations are rarely observed. Mitral regurgitation is more often found in patients with rheumatoid nodules, which allows thinking about the association of valvular lesions and the severity of systemic manifestations of RA. One of the causes of severe mitral regurgitation is the rupture of the structures of the mitral complex 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 method of diagnosing rheumatoid pericarditis is transthoracic echocardiography, which allows to detect effusion in the pericardium and to decrease diastolic filling during inspiration. Auxiliary methods - multispiral computed tomography and magnetic resonance imaging (MRI); The need for these studies can arise when deciding on the question of surgical treatment.

Characteristic for pericarditis changes on the ECG may be nonspecific or absent in patients with RA, however, it is possible to detect such classic features as an electrical alternative, diffuse elevation of the ST segment.

The main method for diagnosing rheumatoid myocarditis is transthoracic color Doppler ultrasound, which allows to diagnose diffuse or nodular thickening of the valves of the mitral or aortic valve, which distinguishes these changes from the echocardiographic signs of rheumatic valvulitis. Daily monitoring of the ECG according to Holter allows to identify ventricular and supraventricular extrasystoles, as well as to assess their clinical significance.

Etiological interpretation of heart defects in RA always presented great difficulties. Vuwaters suggested that there should be 3 subgroups in the group of patients with heart defects and chronic arthritis:

• combination of two diseases - rheumatic heart disease (RBS) and RA ["combined form of rheumatic fever (RA) and RA"];
• true rheumatoid heart defects;
• postreumatic arthropathy Jacques.

Domestic authors described one more variant of the disease, which has the following features:

• the beginning of episodes of reversible arthritis in childhood, adolescence, with the formation in some cases of heart defects, which corresponded to the RA picture;
• joining after a long "light" gap of persistent, chronic arthritis with a typical picture of RA, the presence of extra-articular manifestations (most often interstitial lung fibrosis, Raynaud's syndrome) and seropositive for rheumatoid factor.

However, the rarity of this variant of the disease, the need for many years of careful monitoring of the symptoms do not allow us to hope for rapid progress in understanding the phenomenon in the coming years, which causes grief, for, as Academician N.A. Mukhin, "every patient enriches our ideas about the disease with new details," and quotes R. Vikhrov: "Rare diseases are important because they act not only on our feelings, but also on the mind."

[4], [5], [6], [7], [8], [9], [10], [11], [12]

Treatment of rheumatoid heart disease

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

Prognosis of rheumatoid heart disease

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