Cardiovascular Manifestations and Pulmonary Hypertension in Rheumatoid Arthritis

Udayakumar, N (2006) Cardiovascular Manifestations and Pulmonary Hypertension in Rheumatoid Arthritis. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION: Is it not disgraceful that a person should, by reason that extraordinary arthritis, be unable to use his hands and should need somebody else to bring food to his mouth and to perform the other necessities for him… and even if overlooks the disgraceful aspect of this, yet one cannot overlook the pain these people suffer, night and day. Galen (128 – 200 A.D). Rheumatoid arthritis (RA) is the most common inflammatory arthritis and hence an important cause of potentially presenting disability. Rheumatoid arthritis is a chronic multi system disease of unknown cause. Although there are a variety of systemic manifestations, the characteristic feature of Rheumatoid arthritis is a persistent inflammatory synovitis, usually involving peripheral joints in a symmetric distribution. The potential of synovial inflammation to cause cartilage damage and bone erosions and subsequent changes in the joint integrity is the hallmark of the disease. Despite its destructive potential, the course of RA can be quite variable. Some patients may experience only a mild oligoarticular illness of brief duration with minimal joint damage, where as others will have a relentless progressive polyarthritis with marked functional impairment. Long- term survival of patients with rheumatoid arthritis is shorter compared with the general population or control population without RA1 Among the different causes of death, increased mortality from heart disease with high mortality from congestive cardiac failure was reported in many studies. Necropsy studies showed a high incidence of pericardial, myocardial and endocardial involvement in RA patients. However, cardiac disease is clinically silent and is rarely a life threatening complication in RA. Cardiac failure is the result of either systolic or diastolic dysfunction, or both. Left ventricular diastolic dysfunction is usually attributable to common structural abnormalities such as hypertrophy or interstitial fibrosis and impaired myocyte relaxation resulting from ischemia. In RA, the cardiac disease can present in various forms in relation with granulomatosis and vasculitis. In patients with RA, all layers of the heart can be inflamed and pericarditis is the most common form of involvement. Moreover valvular disease, myocardial involvement, coronary vasculitis and diastolic dysfunction can be identified. Lung involvement in rheumatoid arthritis is not uncommon, comprising pleural effusion, interstitial fibrosis, pulmonary rheumatoid nodules, and involvement of small airways. Pulmonary hypertension has also been described in RA patients. This is usually the result of RA- associated lung disease. Isolated case reports of primary pulmonary hypertension have also been published. Primary pulmonary hypertension is often clinically silent until well advanced. Sub clinical pulmonary hypertension may be more common in rheumatoid arthritis, since Dawson et al. reported that 21% of all the rheumatoid arthritis patients had pulmonary hypertension identified by echocardiography, without significant cardiac disease or lung disease evident upon pulmonary function testing. In fact, at the initial stages of pulmonary hypertension, symptoms may be absent or may be quite unspecific, causing this diagnosis to be missed or delayed. Doppler echocardiography is a sensitive and non-invasive method of detecting cardiac abnormalities and systolic and/or diastolic function and for detecting pulmonary hypertension. There have been no studies from the Indian sub continent on the prevalence of left ventricular filling abnormalities and pulmonary hypertension in Rheumatoid arthritis patients. So we decided to study these parameters and investigated whether they correlate with the disease duration. AIMS AND OBJECTIVES: 1. To study the prevalence of cardiovascular manifestations using echocardiography in rheumatoid arthritis (RA) patients without clinically evident cardiovascular manifestations. 2. To evaluate the left ventricular filling abnormalities, analyzing transmitral flow in rheumatoid arthritis (RA) patients without clinically evident cardiovascular manifestations with special regard to disease duration. 3. To study the prevalence of pulmonary hypertension using Doppler echocardiography in rheumatoid arthritis (RA) patients without clinically evident cardiovascular manifestations and to correlate it with the duration of disease. MATERIALS AND METHODS: The study was carried out on 45 patients (nine men and 36 women, mean (SD) age 34.8 (6.7), range 21-50 years) attending the rheumatology out patient department of Madras Medical College and General Hospital with an established diagnosis of RA, as defined by the American Rheumatism Association 1987 criteria. Duration of the disease ranged from 1 to 17 years. Informed consent was obtained from subjects enrolled and the study was approved by the local ethics committee. 45 normal subjects (nine men and 36 women, mean (SD) age 35.4 (6.5), range 23-52 years) were selected as controls. None of the subjects included in the study had evidence of cardiac disease, hypertension, diabetes mellitus, chronic obstructive pulmonary disease, pulmonary tuberculosis or pulmonary thromboembolism as assessed by history, physical examination, Chest radiography and standard 12-lead ECG. In view of the radiation exposure involved in the study, patients were excluded if they were pregnant or planning a pregnancy. Patients with moderate mitral regurgitation, mitral stenosis or a left ventricular ejection fraction below 64% were considered to have a cardiac cause for their PASP and so were excluded. STATISTICAL ANALYSIS: Continuous data were described as mean and standard deviation (mean +/- SD), and categorical variables as numbers. Comparisons between 2 categories were made using Student t test (2 tailed) for continuous variables. To analyze categorical data we performed the chi square test. Pearson correlation was used to correlate the continuous variables like disease duration and pulmonary artery pressure and parameters of diastolic dysfunction. RESULTS: The main demographic, clinical and laboratory features of the 45 patients with RA without clinical evidence of cardiovascular disease. Women outnumbered men. The mean age at the time of diagnosis was 34.82+ 6.67 years. During the course of the disease, extra-articular manifestations were observed in almost 58% (26) of the patients. Rheumatoid nodules were found in 10 patients, all of whom were rheumatoid factor positive. CONCLUSION: The following are the conclusions from the study; 1. Cardiovascular manifestations are common in Rheumatoid arthritis patients. 2. The relation between transmitral flow alteration and disease duration suggests a sub-clinical myocardial involvement with disease progression and may be related to the high incidence of cardiovascular deaths in patients with RA. 3. The relationship between the pulmonary artery pressure and disease duration and age also suggests a sub clinical involvement of the pulmonary vasculature with disease progression and may be relevant to the high incidence of cardiovascular deaths observed in patients with RA.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Cardiovascular Manifestations ; Pulmonary Hypertension ; Rheumatoid Arthritis.
Subjects: MEDICAL > General Medicine
Depositing User: Subramani R
Date Deposited: 25 Mar 2018 04:59
Last Modified: 25 Mar 2018 04:59

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