When disease activity is high, even early RA patients have a higher risk of non-ischemic heart failure, and male sex in RA raises the risk of both ischemic and non-ischemic heart failure, said Dr. Mankad.7
“Heart failure seen in the RA population is what we call ‘hef-hef,’ or heart failure with a preserved ejection fraction,” she said. “This is a much more complicated entity, and we don’t really know what causes it.”8 RA patients with heart failure are more likely to be hospitalized and have higher mortality rates than the general population.
High inflammation causes arteries to act abnormally, even if they are not obstructed. “They don’t relax or dilate appropriately with the level of activity you are doing. They remain stiff,” she said. Patients may present with chest pain, but their coronary arteries look normal. In the past, cardiologists assumed the test results were off, but now recognize inflammation’s effect on these patients, who have higher rates of silent myocardial infarction and sudden cardiac deaths.9 High inflammatory markers cause an almost equal risk of CVD as smoking or hypertension in RA patients, so consider all of these factors to assess risk, said Dr. Mankad.
Inflammation & Plaque
Paradoxically, a low body mass index is a risk factor for heart disease in RA patients. “It may not be because they are healthier and exercise, but that the inflammatory disease is actually making them too thin. The high inflammatory milieu drives BMI down in these patients,” she said.10
Look for signs of heart disease even in premenopausal women who have lupus. “No matter what your age, having lupus increases your risk of plaque,” she said.11 Hydroxychloroquine and steroid treatment may reduce plaque in lupus patients. “Lupus patients have a lot of CVD risk factors, like all of us do. Hyperlipidemia, hypertension, smoking and sedentary lifestyle are common in the lupus population and this does lead to plaque. If you have lupus and these traditional risk factors, your likelihood of having plaque is higher.”
RA and lupus flares may spike lipid levels, so “if I get a patient’s cholesterol profile, and realize they had a flare at the time, I check it again later, because I just don’t know where they are when they’re at their best.”
Coronary angiograms are invasive and costly, but another option to assess risk is a brachial artery reactivity test, said Dr. Mankad. It uses a blood pressure cuff to test the artery’s dimension before and after pressure. RA and SLE patients often show poorer dilation.
