Heart Failure and Ischemic Heart Disease in Patients With Rheumatoid Arthritis

Heart Failure in Rheumatic Disease: Secular Trends and Novel Insights

There is a significant increase in risk of heart failure in several rheumatic diseases. Common cardiovascular risk factors and inflammatory processes, present in both rheumatic diseases and heart failure, are contributing to this increase. The opportunities for using immune-based strategies to fight development of heart failure in rheumatic diseases are evolving. The diversity of inflammation calls for a tailored characterization of inflammation, enabling differentiation of inflammation and subsequent introduction of precision medicine using target-specific strategies and immunomodulatory therapy. As the field of rheuma-cardiology is still evolving, clear recommendations cannot be given yet.

Cardiovascular risk and mortality in rheumatoid arthritis compared with diabetes mellitus and the general population

Objectives

To compare risk of cardiovascular disease and mortality in patients with incident RA, diabetes mellitus (DM) and the general population (GP).

Methods

Patients diagnosed with incident RA were matched 1:5 by age, sex and year of RA diagnosis with the GP. In the same period, patients with incident DM were included. Outcomes were heart failure (HF), myocardial infarction (MI), coronary revascularization, stroke, major adverse cardiovascular events (MACE) and death up to 10 years after diagnosis.

Results

We included 15 032 patients with incident RA, 301 246 patients with DM and 75 160 persons from the GP. RA patients had an increased risk of HF [hazard ratio (HR) 1.51, 95% CI: 1.38, 1.64], MI (HR 1.58, 95% CI: 1.43, 1.74), percutaneous coronary intervention (PCI; HR 1.44, 95% CI: 1.27, 1.62), coronary artery bypass grafting (CABG; HR 1.30, 95% CI: 1.05, 1.62) and stroke (HR 1.22, 95% CI: 1.12–1.33) compared with the GP. However, the 10-year all-cause mortality was at the same level as observed in the GP. Cardiac death and MACE were increased in RA compared with the GP. When compared with patients with DM, RA patients had a lower adjusted risk of HF (HR 0.79, 95% CI: 0.73, 0.85), CABG (HR 0.62, 95% CI: 0.51, 0.76) and stroke (HR 0.82, 95% CI: 0.76, 0.89), and similar risk of MI and PCI. DM patients had the highest risk of 10-year mortality, cardiac death and MACE.

Conclusion

This study demonstrates that RA is associated with an increased risk of HF, MI, stroke and coronary revascularization than found in the GP but without reaching the risk levels observed in DM patients.

Interstitial Lung Disease in Rheumatoid Arthritis Remains a Challenge for Clinicians

Interstitial lung disease (ILD) is a serious complication of rheumatoid arthritis (RA) contributing to significantly increased morbidity and mortality. Other respiratory complications, such as chronic obstructive pulmonary disease and bronchiectasis, are frequent in RA. Infections and drug toxicity are important differential diagnoses and should be considered in the diagnostic work-up of patients with RA presenting with respiratory symptoms. This review provides an overview of the epidemiology and pathogenesis of RA-ILD, the radiological and histopathological characteristics of the disease as well as the current and future treatment options. Currently, there is no available evidence-based therapy for RA-ILD, and immunosuppressants are the mainstay of therapy. Ongoing studies are exploring the role of antifibrotic therapy in patients with progressive fibrotic ILD, which may lead to a new treatment approach for subgroups of patients with RA-ILD.

Mammalian Target of Rapamycin (mTOR) and the Proteasome Attenuates IL-1β Expression in Primary Mouse Cardiac Fibroblasts

Background: IL-1β is a highly potent pro-inflammatory cytokine and its secretion is tightly regulated. Inactive pro-IL-1β is transcribed in response to innate immune receptors activating NFκB. If tissue damage occurs, danger signals released from necrotic cells, such as ATP, can activate NLRP3-inflammasomes (multiprotein complexes consisting of NLRP3, ASC, and active caspase-1) which cleaves and activates pro-IL-1β. NLRP3 activation also depends on NEK7 and mitochondrial ROS-production. Thus, IL-1β secretion may be regulated at the level of each involved component. We have previously shown that NLRP3-dependent IL-1β release can be induced in cardiac fibroblasts by pro-inflammatory stimuli. However, anti-inflammatory mechanisms targeting IL-1β release in cardiac cells have not been investigated. mTOR is a key regulator of protein metabolism, including autophagy and proteasome activity. In this study we explored whether autophagy or proteasomal degradation are regulators of NLRP3 inflammasome activation and IL-1β release from cardiac fibroblasts. Methods and Results: Serum starvation selectively reduced LPS/ATP-induced IL-1β secretion from cardiac fibroblasts. However, no other inflammasome components, nor mitochondrial mass, were affected. The mTOR inhibitor rapamycin restored pro-IL-1β protein levels as well as LPS/ATP-induced IL-1β release from serum starved cells. However, neither serum starvation nor rapamycin induced autophagy in cardiac fibroblasts. Conversely, chloroquine and bafilomycin A (inhibitors of autophagy) and betulinic acid (a proteasome activator) effectively reduced LPS-induced pro-IL-1β protein levels. Key findings were reinvestigated in human monocyte-derived macrophages. Conclusion: In cardiac fibroblasts, mTOR inhibition selectively favors pro-IL-1β synthesis while proteasomal degradation and not autophagy is the major catabolic anti-inflammatory mechanism for degradation of this cytokine.

Development of heart failure in patients with rheumatoid arthritis: A Danish population-based study

BACKGROUND

To investigate the incidence of heart failure (HF) and ischaemic heart disease (IHD) in different time spans following incident rheumatoid arthritis (RA) and, furthermore, to investigate the impact of IHD on the development of HF and the impact of different treatment era of RA.

MATERIALS AND METHODS

This matched cohort study used nationwide, prospectively collected data. From the total Danish population of approximately 5.7 million inhabitants, we identified 51 859 patients (between 1995 and July 2016) with incident RA and a sex- and age-matched cohort from the general population (256 653 persons).

RESULTS

The hazard ratio (HR) for HF among RA patients compared with persons from comparison cohort was 2.28 within the first year of index date, 1.39 within the 1-5 years of index date and 1.38 within the 5-10 years of index date. No difference was identified regarding different treatment era of RA. For IHD, the subdistribution hazard ratio (sHR) was 1.93 within the first year of index date, 1.26 within the 1-5 years of index date and 1.31 within the 5-10 years of index date. Coronary revascularization was also more common within the first year after diagnosis of RA. An increased risk of percutaneous coronary intervention and coronary artery bypass grafting within 10 years following the RA diagnosis was observed. HR for new onset of HF in RA without IHD was 1.23, while the HR for new onset of HF in patients with RA and IHD was 2.06.

CONCLUSIONS

Rheumatoid arthritis patients had higher rates of HF and IHD throughout the entire observation period compared to the comparison cohort. RA was associated with a larger risk of developing HF.