Introduction:
Rheumatic diseases are considered inflammatory and auto-immune. The auto-immunity is characterized by the self-sabotaging nature of rheumatic diseases. The immune system is well equipped to identify harmful, foreign invasions and fight them to prevent the body from acquiring unwanted infections. However, in auto-immune diseases, the ability of the immune system to distinguish between one’s cells and external microorganisms is disrupted. As a result, the body releases inflammatory chemicals that are targeted to kill the healthy, living tissues. A variety of immunosuppressive therapies are prescribed to manage the immune response of the body. Cardiac involvement has been prevalent in patients with rheumatic diseases. At times, the cardiac symptoms become the root of the diagnosis of the underlying rheumatic condition. Cardiovascular problems appear either silently or are the first signs of display that establish its link with pre-existing rheumatic diseases. These auto-immune rheumatic conditions include Rheumatoid Arthritis (RA), Systemic Lupus Erythematosus (SLE), System Sclerosis (SSc), and Ankylosing Spondylitis (AS). In this article, we will review how different diseases have varied cardiovascular manifestations that may hugely account for one’s mortality rate.
How Is Cardiac Health Affected in Rheumatic Patients?
The increased number of cases of cardiac disorders in rheumatic patients is proof that there is a strong association between the two. The general reasons for the occurrence of cardiac disorders are:
Age: People aged 50 or above are generally at a high risk of developing heart health issues.
Family History: One is more prone to acquiring heart disorders if a blood relative has been affected by it as well.
Other systemic conditions include high blood pressure, high levels of low-density lipoproteins (LDLs), the presence of diabetes, and obesity.
Certain Behavioral Risks: This typically involves habits like smoking, chewing tobacco, consuming alcohol, and living a sedentary life that adversely affects one’s cardiovascular health.
All these factors, independently, can be held responsible for one’s decline in cardiac health. However, the point to be noted here is how the chronic inflammatory action of the immune system in autoimmune rheumatic diseases can also lead to progressive cardiac ill health in these patients. Many cardiac disorders are discovered, typically involving the vascular system (blood vessels), conduction system (electrical signal transmission), valvular system (involving heart valves); pericardium (the fibrous sac enclosing the heart), and myocardium (the muscular tissue of the heart). The persisting chronic inflammation in rheumatic diseases gives way to these cardiac disorders that become one of the main reasons for fatality in rheumatic patients.
Coronary heart disease, in particular, is found to be closely associated with rheumatic conditions.
What Are the Specific Cardiovascular Involvements in Each Disease?
Cardiac Involvement in Rheumatoid Arthritis (RA):
Rheumatoid arthritis is one of the most commonly occurring autoimmune diseases, with about 50 % of all patients having some type of cardiac involvement. The cardiac problems are generally reported to be asymptomatic, meaning there are no clinical signs presented concerning the heart. The mortality rate of rheumatoid arthritis patients is high, mainly due to cardiac disorders. The ischemic heart disease is the most common cause of death in RA patients, wherein the blood flow to the heart is insufficient or obstructed. Another cardiac manifestation involves the atherosclerosis of the carotid arteries. This typically involves obstruction of the arteries due to excess buildup of fats, and lipids around the artery walls, causing the artery lumen to gradually decrease in size. Other cardiac involvements include pericarditis, with about 40 % of people with RA affected by it. Clinically, the patient may be found complaining of sharp chest pains that usually go away on their own in some time. Congestive heart failure is also found to be a common occurrence in patients with RA, alongside various other valvular diseases and cardiac amyloidosis (excess deposition of amyloid protein in the heart).
Cardiac Involvement in Systemic Lupus Erythematosus (SLE):
Systemic lupus erythematosus is another chronic auto-immune disorder that affects women more as compared to men. Black men and women are predominantly affected by this disease relative to whites. The cause for this remains uncertain. However, various genetic, environmental, and immunological factors are said to play their role in contributing to this disease. The main cardiac involvement in SLE patients is the pericardial disease, with 20-50 percent of patients also showing pericardial effusion (Excess fluid accumulation in the outer lining of the heart). Endocarditis can also be commonly detected in echocardiography in patients with SLE. It typically involves inflammation of the inner lining of the heart chambers. Talking about chambers, the left ventricle has been reported to have more structural and functional changes in patients with SLE relative to the normal population. Valvular manifestations are also quite commonly reported in SLE patients, especially mitral valve regurgitation.
Cardiac Involvement in Systemic Sclerosis (SSC):
Systemic sclerosis is a type of auto-immune disorder that has various cardiac disorders associated with it. It is a rare, chronic disease that mainly affects the connective tissue of the body. The fibrosis of the internal organs is one of the main features of this disease. The cardiac involvement ranges from silent to loud and clear clinical signs, with pulmonary artery hypertension being the most serious clinical manifestation among others. Myocardial abnormalities are more commonly reported in SSC patients. The vascular system is affected by an increased amount of stiffness reported in large arteries as well as small vessels of the heart. The electrocardiography can detect various conduction abnormalities and arrhythmias associated with SSC patients. The risk of heart failure is potentially increased in SSC patients with skeletal myositis.
Cardiac Involvement in Ankylosing Spondylitis (AS):
Ankylosing spondylitis is another autoimmune condition characterized by inflammation of the site where tendon and ligament attach to the bone (Enthesis). This disease generally involves the entire spine and some peripheral joints. Aortic disease is the most common cardiac manifestation in patients with AS. This typically includes aortic regurgitation (Improper closure of aortic valve resulting in backflow of blood to the heart) and aortitis (Inflamed aorta). Secondarily, atrioventricular blocks are also commonly reported in patients with AS. Congestive heart failure cases are comparatively more predominant in AS patients relative to the normal population. This owes greatly to the fatality rate among these patients.
Conclusion:
The occurrence of cardiac disorders is often missed by doctors, leading to serious complications of the heart in rheumatic disease patients. Rheumatic diseases are known for their debilitating joint health as well as the inclusion of other organs of the body. Careful supervision of these patients with timely checkups considering all aspects of the disease is therefore advised to avoid unexpected accidents like heart failure or myocardial infarction.
